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TRANSACTIONS
& STUDIES

of

The College of Physicians

of

Philadelphia

FOURTH
SERIES

VOLUME 37
i 9 69-70

WAVERLY PRESS, INC.
Baltimore^ Md. 21202

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act of August 24, 1912.
Printed in U. S. A.

Contents

No. 1, July 1969
Population Avalanche (Mary Scott Newbold Lecture XL)

Chairman Francis C. Wood

Moderator Luigi Mastroianni, Jr.

Participants

Bernard Berelson, Alan F. Guttmacher, Benjamin Viel 1
Life and Health Insurance Today: A Survey for the Practicing Physician

Introductions Francis C. Wood, Theodore H. Mendell

Chairman Vaughan P. Simmons

Participants

Arthur E. Brown Walter A. Reiter, Jr.

Gerald D. Dorman Paul I. Robinson

Albert L. Larson William A. Sodeman

Robert S. Pressman R. Robert Tyson

D. Sergeant Pepper Joseph C. Wilberding 29

Metabolic Bone Disease — Facts and Fancy (Thomas Dent Mutter Lecture

LXXX) Ernest E. Aegerter 71

Memoirs

Leigh ton Francis Appleman (1874-1968) Warren S. Reese 80

Joseph Howard Cloud (1872-1968) Victor C. Vaughan, III 82

Archer P. Crosley, Jr. (1920-1968) John Kapp Clark 86

John Arthur Daugherty (1902-1968). . .Edward C. Raffensperger 83

Andrew J. Donnelly (1910-1968) Paul J. Grotzinger 88

Matthew S. Ersner (1890-1968) David Myers 84

Francis Clark Grant (1891-1967) Robert A. Groff 89

William E. Krewson, III (1908-1968) Edmund B. Spaeth 91

William Harvey Perkins (1894-1967)

Thaddeus L. Montgomery 93

William Whitaker (1880-1968) Frederic C. Sharpless 96

No. 2, October 1969

Dr. William Bryant (1730-86): American Physician and Antiquary

(Kate Hurd Mead Lecture XX) Fred B. Rogers 99

Thomas Jefferson and the Doctors Samuel X. Radbill 106

Felix d'Herelle and Bacteriophage Therapy (Edward Bell Krumbhaar

Prize Essay VIII) Steven J. Peitzman 115

The Public Practice of Midwifery in Philadelphia

W. Robert Penman 124
Notes on the History of Medicine in Hungary George Polgar 133

iv

CONTENTS

Medicine^Music and Academia F. William Sunderman 140

Distillates from Hieronyinus Brunschwig's Book of Distillation

Marion B. Savin and Harold J. Abrahams 149

A Dozen Portraits in the College Hall Fred B. Rocers 158

List of the Kate Hurd Mead Lectures in Medical History, I-XX 166

Memoirs

William Bates (1889-1967) Norbert J. Schulz 167

Martin W. Clement (1881-1966) John Kapp Clark 169

Edward Foulke Corson (1883-1967) Herman Beerman 171

John Arthur Daugherty (1902-1968) Allen W. Cowley, Sr. 173

J ohn^Evan Davis (1908-1968) Baldwin L. Keyes 174

Samuel Creadick Rhoads (1900-1968) Warren S. Reese 176

Reuben Lore Sharp (1897-1968) Thomas M. Kain, Jr. 177

Calvin'Mason Smyth, Jr. (1894-1967). . . .Tito Augustine Ranieri 178
Transactions of the«Philadelphia Neurological Society, 1968-69 181

No. 3, January 1970

Health Care for theJ970's (James M. Anders Lecture XLVlll)

Joseph T. English 191
125th Anniversary Salute: The Philadelphia Birthplace of the American

Psychiatric Association Robert Erwin Jones 198

Memoir of Sir Henry Hallett Dale (1875-1968)

George B. Koelle 202

The Custodianship Cabinet of The College of Physicians 205

Venerable But Vigorous: The College of Physicians

Lucinda P. Rose 243

The Council of The College of Physicians 246

The Staff of The College of Physicians 248

New Fellows of The College of Physicians 250

Memoirs

Delazon Swift Bostwick (1893-1968). . . .Herbert J. Dietrich, Jr. 254

Theodore Cianfrani (1899-1968) Joseph H. Zeigerman 256

WalterS. Cornell (1877-1969) Herbert W. Cornell 257

Lewis Kraeer Ferguson (1897-1968) Paul Nemir, Jr. 259

Harrison Fitzgerald Flippin (1906-1968)

Charles A. W. Uhle 262

Abraham Mapow (1907-1969) Frederick Harbert 265

Ford A. Miller (1895-1968) John D. Corbit, Jr. 266

Gerald H. J. Pearson (1893-1969) Bernard J. Alpers 267

Stanley P. Reimann (1891-1968) Timothy R. Talbot, Jr. 270

Helena E. Riggs (1899-1968) Russell S. Boles 273

CONTENTS

v

Lennard L. Weber (1915-1969) S. Leon Israel 275

A Letter from the Benjamin Rush House Committee 277

No. 4, April 1970

Neurosurgery in Philadelphia

The Philadelphia Neurosurgical Society

Frederick Murtagh, Jr. 281
Dr. Max Peet and His Contributions to Neurosurgery

Philip D. Gordy 285

The Massa Hoax R. Norton Hall 286

Multiphasic Health Testing (Arthur Parker Hitchens Lecture XIII)

Joseph H. Boutwell 291
Philadelphia Medicine in 1841 as Seen by a Visiting Physician

Harold J. Abrahams and Wyndham D. Miles 295

Memoirs

S. Jen-is Brinton (1892-1969) Frederick C. Sharpless 305

John Westgate Hope (1914-1969) C. Everett Koop 306

David Warren Kramer (1890-1969) Harold L. Israel 308

Eugene A. Meyer (1903-1969) Oram R. Kline 309

George Gordon Snyder, Jr. (1908-1969)

Thomas F. Furlong, Jr. 310

Annual Reports

President's Address Francis C. Wood 311

Secretary, 312; Treasurer, 314; Library, 315; Mutter Museum and
College Collections, 336.

List of College Lectures, 1969 339

Transactions of the Sections 340

Officers, Committees, Sections and Administrative Staff of the College,

1970 342

List of Fellows 347

Suggested Form of Bequest 372

Index to Volume 37 373

1

I

I

I

'

(
I

TRANSACTIONS V STUDIES

of

The College of Physicians of Philadelphia

Volume 37
(Fourth Series)

Number i

(July 1969)

Population Avalanche

The Mary Scott Newbold'Symposium*
Chairman

FRANCIS C. WOOD, M.D., President, The College of Physicians

of Philadelphia

Moderator

LUIGI MASTROIANNI, JR., M.D., Chairman, Department of Obstetrics
and Gynecology, School of Medicine, University of Pennsylvania

Participants

BERNARD BERELSON, President, The Population Council,
New York, New York

ALAN F. GUTTMACHER, M.D., President, Planned Parenthood World
Population, New York, New York

BENJAMIN VIEL, M.D., Professor of Preventive Medicine,
University of Chile, Santiago, Chile

(Dr. Wood) I should like to welcome you
all this morning to the symposium, given
under the auspices of the Mary Scott New-
bold Fund, on what we call the "Popula-
tion Avalanche."

Years ago, in the 1780's and 1790's, this
College of Physicians was the only group
of physicians in Philadelphia interested in
the public health and the public welfare.
Along came the AMA, the county societies,
and the boards of health, and this College
more or less abdicated in favor of those

• Mary Scott Newbold Lecture XL, The College
of Physicians of Philadelphia, 1 March 1969, pre-
sented as a symposium.

groups. A few years ago we decided that
the human race was messing up the world
and that we as physicians and citizens didn't
know quite as much as we should know
about these problems, so we started a
series of symposia. This is our fourth. Pos-
sibly it should have been the first, because,
if we didn't have a population avalanche,
we wouldn't have air pollution, water pol-
lution and all that sort of thing.

We have assembled today a group of
people who know what they're talking
about in this field. I shall now introduce
the moderator of this panel, Dr. Luigi
Mastroianni, Chairman of the Department

2

THE MARY SCOTT NEWBOLD SYMPOSIUM

of Obstetrics and Gynecology of the Uni-
versity of Pennsylvania School of Medicine
who has been very much interested in this
area and who has assembled this panel for
us.

(Dr. Maslroianni) I don't suppose it's
necessary to emphasize the great im-
portance of the subject under consideration
today; the great increase in the world pop-
ulation has become a fact. It's a fact with
which we are now living, and the effects of
the increasing population are felt in every
facet of our society.

Of course, as an obstetrician and gyn-
ecologist, I look upon this as something
more than a demographic problem, and
I suppose I've been conditioned to consider
the importance of family planning in terms
of the lives of my individual patients.

One of our panelists, Dr. Berelson,
has referred in past writings to "effective
personal freedom," and actually part of
our task in academic obstetrics and gyne-
cology is to develop methods which will
make it possible for each woman in the
world to exercise "effective personal free-
dom." The problem is a broad one and the
expertise which will be brought to it by
the members our distinguished panel ranges
in discipline.

First, we have Dr. Bernard Berelson. Dr.
Berelson's background has been varied.
Along the way, he was a Dean of the School
of Library Science at the University of
Chicago and subsequently he found him-
self in the broad field of sociology. He
was a Professor of Sociology at the Uni-
versity of Chicago and later a Professor
of Sociology at Columbia University. About
a year and a half ago, he was appointed
President of the Population Council in
New York City. The Population Council,
as many of you know, is an organization
whose efforts are devoted to a study of pop-
ulation problems throughout the world.

Next, we have Dr. Benjamin Viel. Dr.
Viel's field is preventive medicine, and he
is a Professor of Preventive Medicine

and the Chairman of the Department at
the University of Chile.

For many years, Dr. Viel has worked
in the field of public health or, if you
will, preventive medicine. The main
thrust of his activities has been in maternal
and child welfare. Naturally, the field of
family planning is one which has close
association with maternal and child health.
Dr. Viel has had considerable exposure to
the United States, having studied at both
Harvard and Johns Hopkins. His work in
the field of population control has been
recognized as pioneering, especially as it
relates to the problem in Latin America.

We also have Dr. Alan Guttmacher. Dr.
Guttmacher is an obstetrician and gyne-
cologist, I am proud to say, and he is Pro-
fessor Emeritus at Columbia University in
obstetrics and gynecology and former Chief
at Mount Sinai Hospital in New York.
Presently, Dr. Guttmacher is President of
Planned Parenthood World Population. He
has done much to bring the population
avalanche to the attention of the American
public and to the world.

We will ask each of the panelists to
make an introductory statement. We will
start with Professor Viel who will address
himself to the problem as it relates to
Latin America.

Can the Demographic Explosion be
Stopped in Latin America?

(Dr. Viel) The Latin American continent
cannot be considered as a homogeneous
unit. In its vast territory, we find all kinds
of climates, a wide variety of cultures and
different traditions, as well as a racial mix-
ture, which ranges from the European im-
migrant, who has maintained the purity of
the white stock in Argentina and Uruguay,
to the pre-Columbian native, who has not
yet been mixed in some areas of Mexico,
Guatemala, Ecuador and Brazil. Between
both extremes there are racial mixtures of
white, Mongolian and black, each giving

POPULATION AY \! \NCIIK

3

its own characteristic to countries and
j regions.

The tremendous cultural efforts of Spain
and Portugal left, as inheritance, a com-
I mon religion, the Roman Catholic, and
two languages, Portuguese in Brazil and
Spanish in the territory south of the Rio
Grande, with the exception of Haiti and of
British and Dutch posessions in the Car-
ibbean.

During the Spanish domination and
even during the last decades of the 20th
Century, the predominant production in
1 all Latin America was agriculture and the
only sources of energy were men's muscles
and domestic animals. In such conditions,
the existence of a generalized pre-natality
policy was quite logical. Immense terri-
tories available for cultivation and the lack
1 of labor were sufficient justifications for
' the landowners to encourage birth by all
means, even forgetting the religious teach-
' ings that advocated the formation of a
; family under the norms of a responsible
1 parenthood.

The Independence War, long and cruel
in many places of America, was followed
} by a period of anarchy perhaps longer and
' more cruel than the war against Spain;
s both added to our continent a new tradi-
tion, heroic patriotism. A breed of men
willing to die for their countries, but
rarely in disposition to work for their
) betterment, continued with weapons in
their hands in a succession of revolutions
i and guerrilla wars. They devastated fields
and cattle, impoverished areas which be-
fore were productive, and in their wander-
ing as warriors did not have time to
i establish families. The children born of
j different women and in distant lands

I i learned early to admire the man able to

II : impregnate the female, but not to love
i her, as well as the man brave enough to die

)t j in battle, but unable to adjust himself to
), the routine of a daily work,
n For those who were not born landlords,
jf I only the priesthood and the military

career could change the course of their
lives. The Independence War did not
damage the power of the Catholic Church,
l)iu incorporated into our cultural heritage
a piouounccd militarism, for whose con-
sequences we are still paying today.

With the process of industrialization,
changes have taken place, mainly in the
areas in which this process has been pos-
sible and successful, as it has been in the
South Cone of the continent, Mexico, and
the South of Brazil. But the great majority
of our countries are still living in an agri-
cultural-commercial economy.

Where there is an industrial develop-
ment, there is a peasant migration to the
city. The percentage of urban population
increases and becomes a relatively good
indicator of the degree of industrial de-
velopment reached.

If, instead of dividing Latin America
into geographic or climatic areas, we divide
it according to the percentage of the popu-
lation living in urban settings, it is possible
to have a more realistic idea about the
most characteristic facts associated with the
present demographic condition. Using the
basic data given by the study of Puffer and
Griffith (1), we have selected some coun-
tries and grouped them according to the
percentage of population that in 1960 was
classified as urban, and we have compared
these data with the percentage of the pop-
ulation that in the same year was located
in cities of over 100,000 inhabitants. When
both percentages were high for a given
country, we classified it as an urbanized
society with all the proper characteristics
of an industrial system of production.
When both percentages were low, we con-
sidered the country as rural and conse-
quently as having the type of organiza-
tion proper to an agricultural-commercial
economy. Between both types of countries
remains a group that could be considered
as intermediate, that is to say, in the first
stage of industrialization and facing the
problems of such a period, but with the

I

THE MARY SCOTT NEWIiOLD SYMPOSIUM

only difference that these countries the
mortality rate is relatively low, or at least
lower than the one Europe had in the same
stage. The difference we are mentioning is
not the consequence of an ecological equi-
librium, but the result of the knowledge
we have now to fight the infectious dis-
eases.

Classifying 16 countries with the indi-
cated criteria, we have only Argentina and
Uruguay in the urbanized area. Seven
countries appear in the intermediate area:
Brazil, Colombia, Chile, Mexico, Panama,
Peru and Venezuela. In the rural area are
included the following seven countries:
Costa Rica, Guatemala, Ecuador, Hon-
duras, Nicaragua, Salvador and Paraguay.

The lack of statistical information is the
reason we could not classify the Caribbean
countries, but the knowledge we have
about them makes us think that with the
exception of Cuba, all of them could be
included in the rural area.

In each of these three areas, we have con-
sidered (Figure 1) the mortality per thou-
sand inhabitants, the percentage of dead
children under 5 years of age over the
total number of deaths, the birth rate, the

ratio between the number of children en-
rolled in the schools and the total school
age population, and finally, the expected
population in the year 2000 if the observed
conditions for 1960 do not change consid-
erably.

There is no demographic problem in
the urbanized area. Its present low birth
rate allows one to predict an increase to 44
million inhabitants for the year 2000,
which is still a smaller number of people
than Argentina and Uruguay are able to
feed from their vast prairies and with their
immense natural resources. In contrast,
the intermediate area more than duplicates
its population, and the rural area tripli-
cates its population in the same 40 years.
If the health and educational indicators
show a serious situation, the most simple
analysis has to conclude that with such
rate of population growth, the situation
could get worse at the beginning of the )
coming century. Therefore, a vast area of
our continent is bound to suffer a similar
or worse tragedy than India is facing today,
unless rational measures are taken now to
avoid the catastrophe.

It would be naive to think that the

SOME DEMOGRAPHIC FEATURES IN A GROUP OF LATIN AMERICAN
COUNTRIES IN I960

70

10

DISTRIBUTION OF POPULATION

DEATH

BIRTH

EDUCATION

POPULATION IN 1960 AND
IN 2000

(=E
OF
PO

3CF
PUl

NTAGE

BAN

ATION

PEI
LIV
CIT
1

70-
50-
30-
10-

!CE
IN'
IE!
30.(

N

5
i

)0

TAGE
N

DVER
)

DE
PE

12-
10-
8-
6-
«■
2-

AT H
R 1

91
5

RATE

)0

RA

DEAl
5 0\
DEAl

50-
30-
10"

10
■H I
I E R
Hit

I

JN

T
VE

F

DER
OTAL
RAGE

Bl
PE

50-
30-
10-

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1(

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:

5

}

'•2

(ATE

RATIC
GISTE
SCH0(
DREN
PULAT

050-
030-
010-

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R

5L

10

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ED
C
/E
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f

H
R
5

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L.
PO.
-14

480-
470:
150 :

120-

„ 100-

z -

2 80-
_1

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2 60-
40-
20-

\

X

I

in

POP I ' I VTION A\ Al.ANC.ni.

5

present conditions in Argentina and Uru-
guay are the consequence of the high
percentage of urban population. Such per-
centage has been achieved through a cen-
tury of increasing industrialization. The
European inmigrants, who left Europe
with a concept of responsible parenthood,
established their families in the Argentine
prairie, but, after working in the rural
areas, abandoned them, attracted by the
industrial inducements or by the displace-
ment produced by the progressive mech-
anization of agricultural activity. In the
city, they passed through a transition
period, characterized by high birth rate
i and low mortality, but subsequently they
i. passed through a period of decreased birth
; rate, and, as in Europe, this occurred
e without the use of efficient contraceptives,
without a proper contraceptive education
and even before anybody spoke about
ie demographic explosion. This was the logi-
)[ cal consequence of the difficulties of urban
it life, which were increased by the progres-
sive decrease of mortality of a human
tc group whose ancestors had for a long time
, a concept of responsible parenthood. It
ie was this concept that produced the miracle
before a solution was suggested by medi-
cal doctors, demographers or sociologists.
What we are observing today in the
: I intermediate area of our classification does
not necessarily indicate that a similar
phenomenon is occurring. The death rate
I has decreased in a short period of time;
the mechanization of farming together
with industrial growth have encouraged
peasant migration, but nothing indicates
( so far a spontaneous decrease of birth
rate, and, where such decrease exists, it can
be explained by the presence of a middle
class acting in the same way that the

1 European inmigrants of Argentina acted at
| the beginning of the century.
Because of the fact that the newcomer to
the city usually is a man still attached to
rural traditions, who does not associate the
decrease of mortality with the importance

of birth control, we can observe among the
marginal populations of our cities some-
thing similar to what happens in rural
areas, i.e., the large family and high fer-
tility. Only in some isolated areas and in
certain countries is the practice of illegal
abortion common.

The frequency of induced abortion is a
phenomenon which is being studied with
increasing interest. It could be stated that
in 1960 such a method was the only way of
birth control in Latin America. Since all
countries have a young population distri-
bution and the tendency to allow early
sexual relations, it is easy to believe that
the birth rate would be higher and no less
than 50 per thousand. While no better
indicators are found, a possible way to
determine the frequency of illegal abor-
tions lies in comparing the recorded birth
rate of each country with the theoretical
birth rate of 50 per thousand, which we
figured as expressing spontaneous fertility.
The difference between the two rates in-
dicates the approximate frequency of ille-
gal abortion, as it is shown in Table I.

When the woman cannot resort to abor-
tion, multiparity is the rule. If such
multiparity coincides with economic in-
sufficiency, one observes a kind of involun-
tary "infanticide," whose data, taken from
a study done in Chile by Faundez (2), can
be appraised in Figure 2.

It is evident that the present infant
mortality, especially high among those
born after the family has already 3 or 4
children, could be related to the poverty
that the increase in size is producing; but
30 years of experience in medicine has
convinced us that the unconscious desire
of the mother to see her child die is also an
important contributing factor. The later
born are taken to the doctor only when
they are seriously ill, and very often the
instructions given by the doctor are not
properly observed.

A vast area of Latin America is victim of
the demographic explosion. In some

6

THE MARY SCOTT NEWBOLD SYMPOSIUM

TABLE I

Country

Hirth
Rate
in l you

Difference

from
Theoretical
Hirth Rate

% of
Urban
Population

Uruguay

22.3

— 27.7

68.0

Argentina

22.5

— 27.5

66.4

Brazil

33.0

— 17.0

40.4

Chile

33.0

— 17.0

66.2

Peru

38.2

— 11 .8

47.1

Venezuela

42.8

-7.2

63.7

Colombia

44.6

-5.4

50.6

Mexico

44.7

-5.3

50.7

Honduras

44.2

-2.8

22.5

Salvador

48.5

-1 .5

38.5

Costa Rica

49.2

-0.8

34.5

areas, induced abortion appears as a
method of birth control, but in those areas
in which the demographic growth is
greatest, induced abortion is not com-
monly practiced. This situation, plus the
high infant mortality rate, associated with
uncontrolled natality, gives rise to the
following questions: Is Latin America ap-
proaching the end of the transitional
period? Is Latin America ready to start a
spontaneous decrease of natality? In the
rest of our continent, will the same phe-
nomenon occur that has been changing the
demographic situation in Argentina and
Uruguay since the beginning of this cen-
tury?

The facts seem to indicate that the
answers to these questions are negative, at
least in the short run. Since men were
victims for centuries of pre-natalistic teach-
ings advocated by the landlords for eco-
nomic and political interests, supported by
religious norms and justified by the socio-
economic conditions of the epoch, and
since these men have not yet shared the
concept of responsible parenthood, we
cannot expect that they will forget their
ancestors in a short period of time and be-
have as the European group transplanted
to Argentina did.

For our native population, such under-
standing cannot be sudden, and, if it has
to arise spontaneously, maybe time will not

allow a wait for such spontaneous decrease
in numbers. Probably before we observe a
decrease in birth rate, we shall see an in-
crease of our death rate due to hunger,
which already is manifesting its fatal re-
sults in some areas of the continent.

If everything seems to indicate that
Latin America is in need of a policy of
birth control in order to solve its present
demographic problem, and if there are no
precedents to anticipate a spontaneous
evolution as a result of a cultural change
in our population, then the only solution
is to promote a population policy which in-
cludes and encourages birth control. This
is not an easy task, since there are a good
number of opposing factors.

From the social aspect, it seems neces-
sary to insist on the negative influence of
an ancestor formed in centuries by a pro-
natalistic policy and accentuated by the
so called "Machismo," which in our judg-
ment is the consequence of the Independ-
ence War and guerrilla wars that charac-
terized the anarchy period which followed.
Such "Machismo" does not have too mucli
importance, except in the rural area, be-
cause it tends to disappear rapidly under
the influence of education in industrial
environments.

The social factor that seems to have the

INFANT MORTALITY ACCORDING
TO NUMBER OF BORN ALIVE

300r-

or o
— o
n- o

UJ 200

£E 0_
3 w

Q <±
< _l
UJ

Q c3

100

5$

oi lu
z >-

J I I L

_L

1-2 3-4 5-6 7-8 9-K> 11-12 13- More

NUMBER OF BORN ALIVE FROM
THE SAME MOTHER

Fig. 2.

POPULATION AVALANCHE

7

greater influence in our environment is
poverty, which provokes a collective [lus-
tration. In such a condition, there is no
hope for progress, no family organization,
no desire for more education; in brief,
there is no faith in the future. This is the
precise situation where a policy of birth
control must be joined with a policy of
economic development as two parallel
elements that have to go together. Birth
control will achieve poor results if it is not
accompanied by an efficient economic de-
velopment. Such economic development
will not be successful if there is an un-
controlled population growth. As a
Chilean politician put it, economic devel-
opment and family planning are the two
airplane wings that Latin America requires
for the take-off from underdevelopment.

The Catholic religion is another factor
of great importance nowadays. Until re-
cently we were convinced that the discus-
sion with the Catholic Church was only a
matter of methods, since its continuous
and profound teaching of the norm of
responsible parenthood gave rise to a
principle of agreement and the possibility
ol a common understanding. The compre-
hensible attitude and sometimes the coop-
eration of many priests contributed to
our optimism. The encyclical, "Humanae
Vitae," issued in 1968, which put an end to
four years of discussion in the Church it-
self, defeated our optimism. The Catholic
Church decided itself against birth control,
unless practiced by a method which medi-
cal science has proved as inefficient.

The encyclical, "Humanae Vitae," has a
curious peculiarity. In spite of its universal
meaning, it seems to have been written ex-
clusively for Latin America. Obviously, it
will not have any influence in Asia, Africa
or Oceania. Also, it is quite evident that it
will not increase the present low birth rate
of Europe and Anglo-Saxon America. Its
influence will be felt only in Latin
America.

The way in which the policy imposed by

Pope Paul VI will exert influence in our

continent deserves a careful analysis. Our
experience indicates that the Latin Amer-
ica woman's individual behavior will be
affected little or nothing at all. In Chile,
for example, after and before the publica-
tion of the "Humanae Vitae" encyclical,
80% of those women requesting contracep-
tive devices declared themselves to be
Catholic. The true influence of the
encyclical is being felt in the governments,
as well as in the extreme left revolutionary
movements, since these have a subject for
debate.

The encyclical frightens governments
elected by popular will and does not let
them act, since the official church and
the conservative parties are opposed to any
birth control action. If the government
happens to be in the hands of military,
the pro-natalistic policy of the encyclical
coincides completely with the ideas sup-
ported by Latin American militarism,
which thinks of the woman as a soldier-
producing machine and victory in war as
achieved by number. Undoubtedly, our
militarists forget the two last Israel-Arab
wars.

With respect to the extreme left, the
impact of the encyclical is even more in-
teresting to observe. The groups influenced
by Marx in Latin America, or at least the
ones calling themselves Marxists, have held
the view that Marx and Malthus are two
antagonistic thinkers. They maintain that
the demographic problem does not exist,
but only a problem of distribution of
wealth; for them, birth control is an in-
vention of American capitalism to keep
Latin America subjugated; they have
stated that the growth of our population is
the only solution to achieve a change in
the worn-out capitalistic structures. Paul
VI on pronouncing himself an opponent
of birth control by artificial means, is in
favor of a pro-natalistic policy, which
makes possible the dialogue between the

8

THE MARY SCOTT NEWBOLD SYMPOSIUM

Church and the Latin American Marxist
groups.

This sui generis and extremely home-
made interpretation of Marx contradicts
Urlanis (3), doctor in economic sciences of
the Soviet Union, who stated in the Con-
gress held in Sydney in 1967 that "the idea
widely divulged in the world literature
that Marxism is against birth control is
false. Such an idea is denied in many
opinions written by Marx, Engels and
Lenin, and because of this fact birth con-
trol is widely practiced in the Soviet
Union." The same author adds, "The
countries of the Third World must have a
favorable policy towards family planning
and the small si/e family system; otherwise,
they will face unemployment, which
means more consumption than production
and therefore a diminishing chance to im-
prove the level of living." If such is the
official word of a Russian Marxist author-
ity, why does Latin American Marxism
hold just the opposite? We cannot find any
explanation other than a strategy to take
over power. The uncontrolled increase of
our population will bring about (as the
Soviet economist stated so well) unemploy-
ment and a deterioration in the standard
of living, and these factors will be the best
allies of a revolution directed toward
destroying capitalistic structures.

We have adverse factors even in the
medical sciences themselves. The methods
for artificial birth control we know today,
although they are better than twenty years
ago, are still far from perfect; conse-
quently, their deficiencies invite scientific
research to produce improvement, which
could make possible the use of 100% reliable
and efficient methods.

Experience with hormonal contracep-
tives taken orally in Latin American is
only favorable among groups of a high
cultural level and duly motivated. Among
groups where poverty and illiteracy are
predominant, the percentage of failure per
100 year-women of observation has reached

32% (4). We do not have information con-
cerning the use of injectables.

Our own experience (Figure 3) with
intrauterine devices, the most advisable
method for Latin American communities,
shows a relatively greater efficiency among
younger women.

The influence of parity can be seen in
Figure 4, a study of 8,170 women observed
up to 36 months from the time of inser-
tion of the Lippes loop. From such a
study it can be concluded that greater ef-
ficiency of the IUD is obtained in the
woman older than 30 years and who has
had more deliveries. The protection we
can offer to women aged 20 to 30 years is
relatively less, and certainly for the nul-
liparous younger than 20 years of age the
efficiency must be even smaller.

Those who advocate the legalization of
induced abortion find the best argument in
the relative efficiency of our present birth
control methods; the legal induced abor-
tion is undoubtedly an efficient resort to
lessen the harm done by the abortion per-
formed by unskilled hands and useful as a
method of birth control. Although its cost
is high, it should be accepted until we can
dispense more efficient contraceptives than
the ones being used at present.

We who are working in birth control
have against us social factors represented
mainly by the heritage of a pro-natalistic
policy practiced by our native population
for five centuries. We have against us the
frustration and defeatism which results
from poverty without hope. We have
against us the militarism, which inspires
the governmental policies of a good many
countries. We have against us the official
opinion of the Vatican hierarchy, which
introduces fear in many governments. We
have against us the Marxist left, which
changes its doctrine hoping that the condi-
tions produced by the demographic ex-
plosion will lead them to power. Finally,
we have methods of fertility control with
relative inefficiency and the legal prohibi-

POPULATION AVALANCHE

9

tion to practice abortion, except when the
mother's life is in danger.

If Latin America is looked upon as a
whole, what has been done up to now can
be characterized by two conditions: too
little and too late.

In the presence of such a situation, can
it be expected that vast regions of Latin
America will be saved from the same
disaster affecting India nowadays? I am
still optimistic, and my answer is yes, it
can. It is true that we have adverse factors
which are almost insuperable, but based
on the experience of four years of work in
Chile, as well as on the observation of what
other countries have done, we must recog-
nize that we have a factor in our favor.
This is the demand for contraceptive
services by the Latin American woman
when she has the opportunity to know
about such methods. The woman, the
most responsible being of our society,
constitutes our support and our faith in
victory; her response justifies our struggle.
Whenever a well-directed educational pro-
gram offers contraceptive services, accept-
ability exceeds possibility of service.

PERCENTAGE OF WOMEN IN USE OF LIPPE5
IUD AT THE BEGINING OF EACH PERIOD OF
OBSERVATION UP TO THE END OF 36 MONTHS
ACCORDING TO AGE AT TIME OF INSERTIONS.

1 1 1 1 1 1 r-

3 6 12 18 24 30 36

MONTHS OF OBSERVATION

Fic. 3.

PERCENTAGE OF WOMEN 20 29 YEARS OLD
IN USE OF LIPPES IUD AT THE BEGINING
OF EACH PERIOD OF OBSERVATION UP TO
THE END OF 36 MONTHS ACCORDING TO
PARITY.

1 1 1 1 1 1 |—

3 6 12 18 24 30
MONTHS OF OBSERVATION
Fic. 4.

In Chile, a permissive governmental
policy has functioned within the structure
of the National Health Service. Today,
family planning is part of the mother-child
care services, and the experience we are
having induces us to state that the woman
is receptive to education and advising
whenever the doctor offers contraceptives
and especially when she knows that doctors
are also willing to take care of her new-
born child. Integrated health actions will
be able to bring down natality to a com-
patible level with our production; if such
policy is generalized and intensified, then
Latin America could normalize its family
and live under the western social norm of
responsible parenthood.

What we are stating can be evidenced by
the results we have obtained in the western
district of Santiago, which has an approxi-
mate population of 130,000 women in
fertile age. During the first four years of
family planning program, 36,000 women
have accepted the use of contraceptives.

10

THE MARY SCOTT NEWBOLD SYMPOSIUM

This has meant that illegal abortion has
decreased to 70% of the figure registered
for 1964; the birth rate, which in 1964 was
37.4, has decreased to 28 per thousand,
still too high, but significantly lower than
what it was.

Finally, I wish to say that if the struggle
against a high birth rate does not go along
with an effective economic development,
the victory that could be obtained would
be ephemeral, the frustration produced by
poverty could easily destroy responsible
parenthood, and the family would revert
to uncontrolled population growth and its
vicious circle of hunger and death. The
developed countries have, at present, his-
torical responsibility. It is impossible for
Latin America to stand alone against
demographic explosion and to achieve its
economic development.

We are personally involved in this strug-
gle, but, as we analyze the situation more,
we understand better what that politician
said: Latin America's take-off toward de-
velopment can be done with two wings —
family planning and economic develop-
ment. But under the present circumstances
it is too late to think of having our own
wings; these have to be borrowed. If this
does not happen, those who are living in
developed countries will observe the hun-
ger of those who did not get necessary help,
given in time to adapt themselves to a
world different from the one in which only
muscle was able to produce energy and in
which only death freed them from an ex-
cessive population.

(Dr. Mastroianni) Thank you, Dr. Viel.
Dr. Viel has reviewed some of the economic
and social forces which influence popula-
tion growth in Latin America and he has
brought to us the sad fact that in the
Communist world and in Latin America,
family planning is not generally accepted
for reasons which are difficult to under-
stand.

He has also indicated that in Latin
America generally, the hierarchy of the

Church has not joined hands with the
hierarchy of the churches in Austria,
France, England, Canada, Belgium, The
Netherlands and in one or two states in the
United States where the conscience is
looked upon as the court of last resort in
this matter.

Finally, he has pointed out that at this
point in time we do have methods with
which we could make considerable impact
on population growth in Latin America.
His own beautiful study with the intra-
uterine device is one example of this.

We will now ask Dr. Alan Guttmacher
to review the status of the population
avalanche in the United States.

The Population Avalanche
in the United States

(Dr. Guttmacher) President Wood, Mr.
Chairman, it's a great privilege to talk in
this institution that has such a rich history
and to stand in front of the portrait of
Benjamin Rush.

Dr. Viel gave us an excellent picture of
the situation in Latin America and I only
hope that I will be equally adequate to
present the situation as I see it in our own
country.

I would like to remind the physicians
present that the first doctor in America to
become interested in the matter of family
planning was a rather strange and perhaps
brilliant man named Charles Knowlton,
who was born in 1800 and died in 1849. He
was graduated from the Dartmouth Medi-
cal School. I say he is strange because,
among other things, when he was studying
anatomy, he wanted to have his own
cadaver; he exhumed a friend and gave
him part of the bedroom which he occu-
pied during the month of January. He
shared his quarters with the dissected
specimen. Finally, the situation was dis-
covered by the police and Knowlton was
put in jail for two months for illegal dis-
section. I think you will grant he was no
follower of rules.

POPULATION AVALANCHE

11

He became very much interested in ob-
stetrics and in his part of New England
developed an extensive obstetrical practice.
During the course of this practice, he
realized that a great deal of hardship
accrued from unwanted pregnancy.

He found America very ignorant about
contraception and therefore in 1832 wrote
a 75-page brochure called, "The Fruits of
Philosophy," or "The Good Companion of
the Married Couple." The book was writ-
ten anonymously but apparently it was
discovered later than Knowlton had been
its author. He was rewarded by a $50 fine
in Tottenham and three months in jail in
Cambridge, Massachusetts, at hard labor.

The book was modern in its contents in
that he brought forth the urgent need for
family planning and tried to answer the
objections of those who would oppose its
use. He raised the point as to whether
or not increased knowledge of family plan-
ning would be likely to increase promis-
cuity and came to the conclusion that it
would not.

The method of family planning which
he advocated in the book was the post-
coital douche which he apparently had
found in Aetios written some 1200 years
before. He added a local note to its
application. Since he was writing for a
New England populus where indoor plumb-
ing was apparently not the rule, he advo-
cated not only that alum be put in the
douche but some spirits be added as well
to prevent it from freezing. He was a prac-
tical man in addition to being a crusader.

Knowlton was the earliest American
physician to become concerned with con-
traception, but other luminaries stand out.

I always like to remind physician au-
diences that the great Dr. Abraham Jacobi
in 1912 made the matter of family planning
an important paragraph in his inaugural
address as President of the American Med-
ical Association.

There were local physicians all over the
United States who were interested in birth

control and the birth control movement.
You had Dr. Dewees in your own commu-
nity, and at a later date Stuart Mudd,
Joseph Stokes and others, but as a whole
until relatively recently, the medical pro-
fession has been very resistant to involve
themselves in the matter of family plan-
ning.

I have tried to think why the medical
profession should have been resistant and
I'm not sure I know all the answers; how-
ever, I should like to suggest several.

One is that in medicine we are immedi-
ately and repeatedly taught the importance
of preserving life. It is probably the main
tenet of our creed and therefore the doctor
may have had some difficulty in making
the intellectual synapse between saving
and preventing life. He didn't realize that
by preventing life, perhaps he was saving
life as well.

In the second place, we had been taught
the fact that the doctor should not do any-
thing about which he is uncertain.

The Latin phrase, non nocere, do no
harm, was emblazoned on the walls of the
Lying-in Hospital in Chicago, facing the
stool upon which the obstetrician sat
when he was to do a forceps. From time
immemorial the medical attitude has been
that if there is doubt, don't do it.

In other words, in medicine, a sin of
omission is not as great a sin as a sin of un-
wise commission.

In the third place, the doctor did not
want to enter the area of controversy par-
ticularly when there were such great reli-
gious overtones as there were decades ago
about the problem of birth control. The
doctor who worked in the early Planned
Parenthood clinics was even refused a
staff position in Catholic hospitals; it was
that strong a prohibition.

Fourth, in the main, the doctor in Amer-
ica has not been a leader in social chanse
and progress. We have been among those
who follow rather than those who lead.

Finally, perhaps the doctor took it for

12

THE MARY SCOTT NEWBOLD SYMPOSIUM

granted that because he knew birth control
his patients were equally conversant with
it.

At all events, it is quite clear that the
American birth control movement does
not stem from medicine. It stems from
early twentieth century feminism. Margaret
Sanger, who actually established the Amer-
ican movement and made of it such a vital
and viable thing, was not primarily inter-
ested in it because of birth control but
simply as an important vehicle to raise
the status of woman, to try to emancipate
her from sexual servitude under which
she served at that time.

The American birth control movement
has a great deal to thank Mrs. Sanger for;
had it not been for her brave obstinancy
and extraordinary talent, the movement
certainly would not be where it is today.

It is probably unnecessary to mention
to so intelligent an audience that Mrs.
Sanger opened the first birth control
clinic in the United States on October 16,
1916, in Brownsville, a slum area of Brook-
lyn.

As you may recall, in the first week she
could not recruit a physician to staff the
clinic because it was so hot a topic that
physicians were afraid to traffic with a med-
ical activity of such uncertain virtue. So
during the first week, Mrs. Sanger and her
sister took the history of 464 potential
patients who came to the clinic to seek
birth control advice. Mrs. Sanger took the
histories so that, when she was able to re-
cruit a physician, there would be less time
lost in giving birth control service. You
probably know that ten days later a police-
woman disguised as a patient came in, had
her history taken, bought a small pamphlet,
"Family Limitation," which Mrs. Sanger
had written on birth control, and, after
she had stuck it in her handbag, blew her
whistle and the cops came in and Mrs.
Sanger, her sister and the records promptly
went out. Mrs. Sanger and her sister went
to jail and the records made a great bon-

fire at the intersection of two important
Brooklyn streets.

Since then, the American medical pro-
fession has become deeply involved in birth
control. Physicians like Dr. Robert Latou
Dickinson, one of our eminent medical
leaders, and others had great influence on
this. My own revered chief, Dr. J. Whit-
ridge Williams at the Johns Hopkins, was
not unimportant in having the medical pro-
fession accept birth control as part of nor-
mal medical care.

I remember in Baltimore, where I was a
resident, when we established the first birth
control clinic. It was established by four
great professors of the Johns Hopkins, but
it was considered unwise to establish it
within the precincts of the hospital, and
therefore the first birth control clinic was
five blocks away from the hospital at 1029
North Broadway. Thus, in 1927 the corri-
dors of the great and sacred Johns Hopkins
remained uncontaminated by birth control.
The same men ran the birth control clinic,
but not under the same roof. After two
years, seeing that nothing extraordinary
happened, in 1929, we opened a birth con-
trol clinic within the confines of the Hop-
kins Hospital.

The fact that many, many U.S. hospitals
have birth control clinics is a relatively new
development, for contraceptive service was
very slowly accepted by American hospitals.
They had no feeling of responsibility either
to their patients or to the education of
their staffs. This retarded the progress of
birth control in this country tremendously.

What is today's American scene? There
has been a tremendous development of the
Planned Parenthood movement in this
country so that currently there are 164
cities with affiliates of Planned Parenthood
World Population. Thirty-two are what we
call educational affiliates. These do not
operate clinics but stimulate and intellec-
tualize the community about family plan-
ning and cooperate extensively with setting
up birth control facilities in existing hos-

POl'L' I .ATION AVAI.AXCH F.

pitals and health departments. In the other
132 cities, we operate some 480 clinics
and see about 350,000 women in the course
of a year, 275,000 of whom are poor or near
poor and within the group called medi-
cally dependent.

Today, unlike yesteryear, there are other
organizations furnishing birth control to
needy patients. Health departments in the
United States have taken up the cause and
each year more counties and more states
are involving their own health departments
in the service of family planning.

It is estimated that in the year ending
June 30, 1968, the last date for which
we have an estimate, 350,000 indigent
women were given contraceptive care by
U.S. Health Departments and another
250,000 by hospital clinics.

It is felt, and this is a rough estimate,
that approximately 875,000 medically in-
digent women are getting birth control ad-
vice either through planned parenthood or
through the health department or hos-
pital of their areas.

No doubt, private physicians give birth
control advice to many indigent patients,
some on Medicaid plans and other reim-
bursement schemes. The volume is very
difficult to estimate, but just to make our
figures come out neatly, we will say 125,000
patients in 1967 received such service from
the physician.

If that is correct then, one million medi-
cally indigent women in this country are
receiving birth control through public
sources, with the private physician receiv-
ing some type of public reimbursement.

Is one million the number that need
such service? It is not thought to be. Ac-
cording to census data for 1967, there were
7.9 million women of the medically de-
pendent group of reproductive age in this
country. It was assumed by some other
statistical maneuver that 2.6 million were
either pregnant or seeking pregnancy, which
left 5.3 million women of the medically
dependent group of reproductive age who

are not seeking pregnancy or pregnant.
This then would mean that of one million
served, we would have a deficit of 4.3 mil-
lion women yet in this country who remain
unprovided for.

These figures are estimates made by the
Health Statistics Bureau of the U.S. Govern-
ment under Dr. Arthur Campbell and by
my own group. They are very rough and
may not be accurate, but nevertheless, they
point out that in America there still is
a large reservoir of medically indigent
women who are not yet receiving modern,
effective contraception.

It does not mean these women are not
using any contraception, because we are a
nation of contraceptors. As Dr. Berelson
pointed out at our breakfast meeting this
morning, probably some 90% of fertile
Americans not seeking pregnancy use some
attempt to limit their fecundity, but cer-
tainly there is a great difference in the ef-
fectiveness of the methods used by those
who are of the affluent, educated group
and those methods used by the uninstructed
and less affluent group. Therefore, our
task is not necessarily to persuade the
women yet unserved to use birth control,
but to use better birth control.

There have been many studies on desired
U.S. family size; according to the studies,
it has been shown that the poor and near
poor desire slightly smaller families than
those in the non-poor group. These figures
show a desired family size of about 2.9
children by the near poor and the poor and
3.3 children by the non-poor group. If such
figures are reasonably accurate and I as-
sume they probably are and we were able
to give the poor the same effective birth
control which is available to the affluent,
we would see a decrease in their family
size, and probably equality between the
family size of the affluent members of our
community and of the poor and near-
poor members.

Currently there is quite a difference in
the fertility rate between the two groups.

14

THE MARV SCOTT NEWBOLD SYMPOSIUM

I am quoting figures collected between
1960 and 1965. In that period, the poor and
near poor had a fertility rate of 153, which
means number of viable pregnancies per
thousand women of fertile age, 15 to 45,
while the non-poor had a fertility rate of
98. There is then a gap of 55 points be-
tween the fertility rate of the two groups,
the poor and the middle class.

Dr. Arthur Campbell has published data
on the estimated number of unwanted
children born in this country each year.
Families were surveyed to find our whether
or not the last child was a wanted child.
An astonishing figure was found, even with
the child crawling around the mother's
apron strings. Over 25% of last children
born in this country when the survey was
made were unwanted children.

On this basis, Dr. Campbell estimates
that of four million births, which was the
average in the 1960-65 period, 850,000
were unwanted, that is, 23%.

There was a difference between those
in the non-poor status and those in the
poor and near-poor group. Forty per cent
of the last children born to the poor and
near poor are unwanted, while only 14%
of those born to the non-poor group are
unwanted.

All this leads me to conclude that we
cannot become complacent and say since
Americans are a nation of contraceptors
we have no fertility problem. We obviously
have a problem. We have a great prob-
lem with vast unmet needs. The question
is how best to serve these needs.

It is obvious that there must be complete
cooperation between all birth control fa-
cilities. In this community, you have
many interested groups. You have the
Planned Parenthood group. You have the
Better Family Planning group. You have
many hospitals with clinics. You even have
Catholic hospitals, I believe, with rhythm
clinics.

I understand there is also beginning
involvement of the Health Department.

What we need to do in all America is to
try to mobilize the full potential. At the
national office in New York, under grants
from the Kellogg, Rockefeller, and Ford
Foundations as well as several other lesser
foundations, there has been established the
Center for Family Planning Program De-
velopment. This group of professionals
will take city after city and try to analyze
the birth control facilities now operating
within the particular community.

We are working currently in Dallas and
have worked in Los Angeles. I don't know
which is the next city selected for such in-
tensive analysis. It may be your own. An
attempt is made to assess how much of
the birth control need is being met in the
particular community and to find out what
the existing facilities are to meet the need.
The attempt is made to stimulate existing
facilities to liquidate the unmet need ra-
ther than to open up new Family Plan-
ning clinics under Planned Parenthood
auspices.

The goal is to have every hospital con-
duct a vigorous, vital, productive clinic,
not a clinic that simply makes obeisance
to the fact that it is doing a little family
planning work, but a clinic which is vital,
interested and organized for the specific
purpose, a clinic which meets not only on
Thursday afternoon but at night or on
Saturday morning or Saturday afternoon
if the need exists. It is essential that we
stimulate existing facilities in the whole
health field, that is, Health Departments
and hospitals, to do the task and do it
with real spirit.

To meet the unmet need in some com-
munities, we will still have to open new
birth control clinics operated by Planned
Parenthood. This is regrettable. Recently
I was in Lansing, Michigan, which is the
home of a huge university, Michigan
State. Perhaps it is known best for its foot-
ball team although it is an excellent school.

They have 40,000 students, 23,000 men
and 17,000 girls. The only family planning

POPULATION AVALANCHE

15

service given in that community is given
by the Health Department, which in fact
has just started. They see about 500 pa-
tients per year and because of political
considerations cannot take unmarried
coeds. The University feels no responsibility
toward the unmarried coed and her birth
control problem. Lansing is a very con-
servative medical community. In addition,
the doctors are very busy. I talked to some
of the obstetricians and they made it quite
clear that they would not welcome an in-
vasion of coeds in their offices. Here then
is a large segment of the population un-
served by existing medical facilities and is
not likely to be. It may very well be that
we will have to open a Planned Parenthood
clinic in this community largely to serve
unwed college students.

They certainly deserve the service and
need it badly. I see no point in discrimi-
nating against the middle class simply be-
cause we are intent on serving the poor.

If there is an unmet need among the
middle class, it must be served in some
way. In the area of birth control, we must
be realistic and try to supply the need
wherever the need exists.

There are many portents to make us
realize that from the point of view of con-
ception control all is not well in America.
I need not remind you that we shall have
300,000 illegitimate children born this year.

The illegitimacy rate is up to 8.7%.
This is not excessively accurate because a
lot of births that are illegitimate are re-
gistered as legitimate, so that the rate of
8.7 is a minimum figure. Then, too, one-
sixth of brides are pregnant when married
in this country.

If we consider all children illegitimate
who are born less than nine months after
marriage, it would increase the illegitimacy
rate to about 25%, taking the 8.7
and the 16% and adding them. By
this definition any pregnancy leading
to birth initiated outside of marriage is
illegitimate. Perhaps this should be termed

the social illegitimacy rate in contrast to
the legal illegitimacy rate.

There are an estimated one million il-
legal abortions done in this country each
year. This figure is a gross estimate; it
may be greater, it may be less, but it's
a vast number. I think on these two indices,
illegitimacy and illegal abortion, we are
forced to admit that we are not doing too
good a job with birth control either among
the poor or the rich.

The facts proving reproductive chaos
present a challenge to all of us. Each of
you is interested in family planning or you
would not be here. This presents a chal-
lenge to each of you individually, to think
this through and see how these multiple
problems can best be met: the problem of
illegitimacy, the problem of forced mar-
riages, the problem of teenage divorces, and
the fact that illegal and legal abortion are
both highly discriminatory. All of this socio-
medical pathology must be put into proper
focus; it exists and can not be swept under
the rug.

In addition, we must take full cognizance
of the fact that our work among some
militant minority groups, is considered
genocidal. They charge that what we are
doing is not really trying to give a better
family life to the less privileged segments
of the community but trying to retard the
numerical growth of ethnic minorities.

This was first brought to my attention
five or six years ago when I was lecturing
at the University of California. For the first
time in a long life I was picketed, and this
fascinated me. I was picketed by a group
called EROS, so I went down and chat-
ted with the pickets who were very intelli-
gent-looking black men. EROS means
Endeavor to Raise Our Size. The group
said that there had been no Catholic
president until there were 40 million
Catholics in America and since there were
then only 21 million Negroes they had to
double their numbers as rapidly as pos-

16

1 I IK MARY SCOTT NEW BOLD SYMPOSIUM

sible. They protested the work of PPWP as
a form of genocide.

You know full well that the program of
family planning is purely voluntary. Coer-
cion is and must continue to be left out
of it wholly, totally and completely.

Let me cite a recent episode. Three
young women were brought before Judge
Perry Bowen in Prince George County
in Maryland because between the three
they had had eight illegitimate children.
Judge Bowen decreed that unless they
practiced family planning, he was going
to take their children away. This was the
edict from the bench.

This is hardly the best way to intro-
duce family planning into America. You
do not discriminate against people and
single them out because they happen to be
poor and unfortunate enough to have il-
legitimate children and make them practice
family planning by an order from the
bench. We defended these young women by
presenting an amicus curae brief. In the
Court of Appeals the defense was upheld
by a six to one decision. If proof is needed
that our philosophy is neither coercive
nor genocidal, this case ought to prove it.

In America, birth control should be ac-
cepted by the individual because she or he
thinks that it is important and right for
their family pattern.

It is time that we come to grips with
two methods of family planning which we
have a tendency to skip over in this country.
One is abortion. I doubt that any of you
is satisfied with the archaic, punitive,
medieval law which now exists in your
state and in mine which permits abortion
to be done only to preserve the life of the
mother.

Almost all realize that liberalization of
the abortion law is absolutely essential to
permit the practice of good, honest medi-
cine, not hypocritical medicine, but honest
medicine.

The question is how extensively should
we liberalize the law. Some people say we

should have abortion on demand. I am
sure that your children, certainly your
grandchildren, will live in an America
where there is abortion on demand.

But I think currently lay America is not
ready for it; I am not sure the medical pro-
fession is ready for it, nor do I think I am
ready for it. I am ready for it in the dis-
tant forty years, but I'm not ready for it in
the current situation. However, I am to-
tally dissatisfied with the American Law
Institute statute because it allows abortion
only to preserve life or health, when there
is likelihood of a child being born mal-
formed or retarded, or evidence of sex
crime, rape or incest.

The states that have put the A.L.I, stat-
ute into operation have found that it has
done little to increase the incidence of legal
abortion. In Colorado, the legal abor-
tions done before the bill was put into oper-
ation were 51 per annum and after the bill
had been in operation for one year there
were 407.

We find that in California the legal
abortions before the bill was put in oper-
ation were 500, and after the bill has been
in operation for a year, about 6,000. It is
estimated that there are 80,000 illegal abor-
tions in California annually. Subtracting
6,000 from 80,000, leaves still a huge sur-
plus of illegal abortions, 74,000. Who is the
surplus? A lot of the surplus are unmar-
ried children, children less than 16 years
old.

I cannot believe that it contributes to
the welfare of the child or the community
to compel a child of less than 16 to bear
an illegitimate child or seek the services of
an illegal abortonist.

To me, either choice is insane and I see
no justice in it. It stems from punitive,
puritanical reaction which has no basis in
logic. Furthermore, a lot of the people who
patronize the illegal abortionist are women
who have had four or five children. I
contend that any woman who has borne
four children should certainly be in the

POPULATION AVALANCHE

17

ideal position to determine whether a fifth
child w ill be an asset to that home.

Is a doctor, judge, or social worker in a
better position to decide that a fifth child
will be ail asset to the home than the
mother who has already borne four?

I could go on and spell out how Pennsyl-
vania should liberalize its abortion law,
but unfortunately you will end up no
doubt getting a bad law like they have
gotten in Colorado, North Carolina, Geor-
gia and California.

The only state that has passed a humane
law is my native state, Maryland. Mary-
land has removed abortion from the penal
code and put it under the Medical Practice
Act. Since the passage of the new statute,
two of Baltimore's hospitals with courage,
the Johns Hopkins and the Sinai, are doing
a relatively large number of legal, justified
abortions.

Furthermore, I think we fail to use steri-
lization correctly. The incorrect use of ster-
ilization is what many of the legislatures
of the Southeast are attempting to do, to
make sterilization mandatory after a woman
has had two illegitimate children.

W herever I go in the South, I find such
a law is before the legislature, and it
takes a lot of fighting to keep such a harsh,
discriminatory law from being passed.

Sterilization should always be, as far as I
can see, a purely voluntary procedure
sought with enthusiasm by the patient.

We need to change the attitude of the
medical profession toward sterilization.
I was in Jacksonville, Florida, yesterday
and I heard sterilization discussed. In
Jacksonville, doctors are even afraid to
sterilize a woman after she has had six
living children. Why, I ask? Well, it's the
rules of the hospital. Well, how do you
change the rules of the hospital? Well, the
staff makes the rules of the hospital. How
do you make the staff understand that
three or four living children would present
a radical indication for voluntary steriliza-
tion?

Well, we'll have to have a campaign to
do it. What has to be done is to gird up
the loins of some doctors who'll take the
ball, carry it and score the goals.

I hope I've given you some insight into
what's good and what's bad about the
American birth control scene. I would
like to point out one fact: the birth rate is
doing something very interesting. It has
come down very sharply, so that it has
fallen from 25.5 per 1000 in 1957 to 17.6,
the estimated rate for 1968. We have had
a downward birth rate curve in America
for a long time; Dr. Berelson says for 150
years.

And the curve is still going down. Cur-
rently it is the lowest birth rate we have
had in our history. It probably is not all
due to modern birth control because dur-
ing the depression years, when we did not
have the IUD or Pill, our birth rate went
as low as 18, but I think that the modern
contraceptive method has contributed to
the current decline. The birth rate is
lower for two reasons. Despite the fact that
the marriage rate has gone up, the birth
rate has gone down; the number of first
births has gone down. Americans are post-
poning the first child and also having
fewer more than 4-child families. These
two factors are bringing the birth rate
down, at least temporarily.

Are these people postponing their chil-
dren and going to begin to go into produc-
tion soon? I have a feeling they will; then
the birth rate is likely to go up again.

(Dr. Mastroianni) Thank you, Dr. Gutt-
macher. Dr. Guttmacher has put the birth
control movement in the United States in
its historical perspective and has brought
us up to date on some of the issues in
modern American society. He has properly
emphasized the importance of personal
freedom of choice in this matter, and,
finally, has touched on abortion and
sterilization, two issues which deserve care-
ful consideration.

We have asked our third panelist, Dr.

18

THE MARY SCOTT NEWBOLD SYMPOSIUM

Bernard Berelson, to discuss the popula-
tion avalanche as reflected in world terms.

Population Problems in the
Developing World

(Dr. Berelson) Anyone who gives even
cursory attention to public affairs these
days cannot fail to know that there is a
population problem in the developing
countries. The so-called "population ex-
plosion" featured in dramatic headlines is
high on the list of topics most often viewed
with alarm. What exactly is the nature of
the population problem? What are its
origins and what are its consequences?
What is being done about it? And what
does it have to do with the medical com-
munity?

Let me begin by speaking to a number
of popular misconceptions on this matter.

Misconception No. 1 is that human num-
bers themselves are overwhelming us.
However, the enemy is not a number but
a rate. According to the latest United
Nations figures, the population of the
world is now growing at the rate of about
2% a year. That rate may seem to be
small, but the fact is that the world's popu-
lation has never before grown at such a
pace for any extended period of time, and
the consequences can be severe. This is
literally a unique situation in human
history.

The population of the world is now
about 3.5 billion, and we are adding over
65 million people every year (about the pop-
ulations of England, The Netherlands, and
Switzerland combined), or approximately
1.25 million people a week. At 2% a year,
a number doubles in about thirty-five
years, so at the turn of the century the
population of the world will be 7 billion
if the present growth rate continues. It
took all of human history up to about 1850
to produce a world population of 1 billion;
it took only seventy-five years for the
second billion, and thirty-five years for
the third. At the present rate it is taking

only about fifteen years for the fourth
billion, and it will take only ten years for
the fifth. These are striking figures. What
they indicate is that the world cannot sus-
tain such a growth rate for very long. Over
the long run, as a recent report by the
National Academy of Sciences put it,
"either the birth rate of the world must
come down or the death rate must go
back up."

Misconception No. 2, signalized perhaps
in the very term "population explosion,"
is that the current unprecedented growth
rate is caused by an increased birth rate.
The opposite is the fact: it is caused by a
decline in the death rate, a decline that
has accelerated greatly since the end of
World War II, particularly in the de-
veloping countries. The decline is due to
improved food production and distribu-
tion, more effective social organization,
and particularly, thanks to the medical
community, to the mass application since
World War II of modern public health
measures such as vaccines, antibiotics, sulfa
drugs, and the new insecticides. In other
words, the world death rate has been re-
duced largely because death control has
been successfully exported from the de-
veloped to the developing countries. As a
result, the rate of population growth is
now much higher in the developing
world, that is, in that two thirds of the
world (Africa, Asia, and Latin America)
where the birth rate is over twice that of
the United States or Western Europe. If
all the countries of the world were listed
in order of their birth rates and a line
drawn at 30 per thousand per year, the
differentiation between the developed and
the developing countries is virtually com-
plete.

Hence, the burden of population growth
falls where it can least be accommodated,
and the politically dangerous differentials
between the have and the have-not nations
are thus sharpened by the most basic of
life processes. It is no exaggeration to say

POPULA1 ION AVALANCHE

19

that there are two kinds of countries in
the world today: those with a high stand-
ard of living and low fertility and those
with a low standard of living and high
fertility.

Those misconceptions have to do with
the nature and the cause of the problem.
The next two have to do with the con-
sequences.

Misconception No. 3 is that population
density is at the heart of the matter, or, in
the popular phrase, that soon there will
not be standing room on the earth. Given
present birth rates, at some point in the
distant future, of course, there will be no
more room, assuming by that time man's
ingenuity has not found a way of extend-
ing the finite limits of this globe. At pres-
ent, density does raise health questions as
well as esthetic considerations, but under
most conditions density is not closely re-
lated to the problems of population expan-
sion as is illustrated, for example, by the
relative prosperity of crowded Hong Kong
or for that matter of the large cities in the
United States. In this regard, it is salutary
for Americans to remember that the most
densely populated areas in the world to-
day include not only Japan, Java, East
Pakistan, and The Netherlands, but also
the eastern seaboard of the United States
from Boston to Washington.

Misconception No. 4 is a more serious
matter: that we will not be able to feed
the population anticipated for the next
few decades. The experts differ on this
subject. Some predict that the world will
soon be in real trouble on this score, but
others believe that we shall just be able to
get by. At best, it appears that the race
between people and food will be a close
one. Modern improvements in technology,
not only in agriculture but also in com-
munications and transportation, perhaps
will enable us to feed the projected in-
crease in world population — not to feed
them well but at least to keep large num-
bers from starving to death as in the not-

so-distant past. Large-scale famines, like
large-scale epidemics, are now more amena-
ble to control. People will not get a healthy
diet, here and there some will die of mal-
nutrition, and many major countries may
have to depend on imported food. But
more people will survive.

That brings me by way of summary to
Misconception No. 5, the underlying one:
that the population problem is a matter of
quantities. Quite the contrary, it is a mat-
ter of human quality — of people with a
decent chance at good health and nutri-
tion, at literacy and popular education, at
good housing and rewarding occupations,
at individual opportunity and fulfillment.
At bottom the problem is to keep the
quantity of human life from diminishing
the quality of human life throughout the
world. What kind of population do we
want, not how many: that is the real
question.

Thus the basic issue is very broad in-
deed. It has to do with the entire social
and economic development of the poorer
countries. Such countries are now seeking
to transform their traditional agrarian sub-
sistence societies and become twentieth
century nations. At best that is not an easy
task, but it is made all the more difficult,
perhaps prohibitively difficult, when it
must be done with the additional burden
of a heavy population growth. If the
population grows at the rate of 2.5 or 3%
a year, it takes the same rate of economic
growth simply to stay even. In the develop-
ing countries a very large part of the
product is consumed daily in the struggle
for immediate survival, and such countries
are hard put to raise the national capital
for .the factories, roads, fertilizer plants,
irrigation networks and machinery that
will yield a better life tomorrow. This is
where the population pressure rubs.

There are two other factors that are sel-
dom appreciated as being important in the
total situation. First, by virtue of the high
birth rates, large proportions of the popu-

20

THE MARY SCOTT NEWBOLD SYMPOSIUM

lation in developing countries are chil-
dren. This situation requires that the
countries invest substantial amounts in
such social services as education and
health. In many countries more than 40%
of the population is under fifteen years of
age, whereas this figure is more like 25%
in the developed nations. Thus, develop-
ing countries have not only a large overall
growth rate to contend with but a large
proportion of dependent youth as well.

The second factor is the "effective per-
sonal freedom" of couples throughout the
world to determine the number of chil-
dren they will have and when they will
have them, in accordance with their own
religious beliefs and personal preferences.
Today, married couples do have that free-
dom in law or in principle, but because of
ignorance and poverty and because proper
information and services and supplies are
lacking, the poor people throughout the
world are not effectively free in this re-
spect. Ideally, the Indian villager should
have the same effective right to control
family size as the Main Line resident; yet
since this right is so much taken for
granted by us, we tend not to recognize
how vital it can be to others.

So over the next years, the populations
of the developing countries will surely
grow. There is hardly a realistic alterna-
tive. The 500 million population of India
and the 100 million of Pakistan and Indo-
nesia, for example, will almost certainly
double. The question is whether these
countries can have sixty years in which to
do so instead of twenty-five. Short of major
catastrophe, no developing country will
have fewer people than it has today. The
question, then, is not whether there will be
growth but rather whether the growth
will be very fast or only moderately fast.

As a solution to these problems, emigra-
tion can be immediately ruled out. There
are simply no facilities or funds for such
mass movements as took place in Europe in
the nineteenth and early twentieth cen-

turies, no place for the far greater num-
bers involved to go, no political atmos-
phere for the forced migration that would
be required, no time for such movement to
take effect. Nor can we discontinue efforts
to improve public health. Once death con-
trol is available, it will not willingly be
relinquished. If anything, that side of the
equation will continue to decline as more
and better public health measures are
applied. Nor can the nations involved af-
ford to wait for the natural process of
economic, educational and medical de-
velopment to result in a lowered birth
rate, as it has in the West. There simph
is not time, considering the rapidity with
which modern medicine and public health
have reduced the death rates in the de-
veloping world. As noted earlier, popula-
tion growth itself has now become a major
obstacle to technological advance. The
dilemma is poignantly real: population
growth is so rapid as to prevent or retard
the emergence of the very conditions that
history shows to be capable of reducing
growth rates through reducing birth rates.

The solution then is to reduce the birth
rate, and to do it reasonably soon.
Throughout most of man's history, a high
birth rate was necessary for survival of the
community because the death rate was so
high. Today, a high birth rate is contrain-
dicated wherever people are reaching for
the benefits of modernization.

This state of affairs has increasingly been
recognized by the governments of the de-
veloping world, and in recent years some
20 countries have established national pro-
grams to bring family planning to their
people. In the developing world today,
about 65% of the people live in countries
with such favorable policies. The move-
ment began in Asia and has made most
headway there; as a result, approximately
80% of the developing population in Asia
lives in countries that accept and en-
courage family planning as against only
20% in Africa (mainly in the northern

POPULATION AVALANCHE

21

tier) and 15% in Latin America. Thus,
attacks on the population problem have
become a matter of governmental policy in
developing countries in a remarkably short
period of time. It is in fact difficult to
think of another movement of such com-
bined delicacy and magnitude that has
made similar headway, and especially so
when the apparent religious, political and
cultural obstacles are taken into account.

It is generally believed that once a
favorable policy toward birth control and
family planning has been established, the
successful implementation and operation
of a program depends upon three factors: 1.,
interest on the part of the people, 2., a
suitable and acceptable contraceptive tech-
nology, and 3., the organization to bring
one to the other. Studies have shown that
interest exists in surprisingly large meas-
ure, even in the rural areas. With the de-
velopment of oral contraceptives and
particularly of the new intrauterine de-
vices, the technological position is far
better than it was only a few years ago,
though major improvements are still
needed. What many of the programs still
lack is the third ingredient: an effective,
vigorous, skilled organization to administer
and conduct the program. Among other
things, the underdeveloped world is un-
derdeveloped in efficient administration,
medical and otherwise. The important
thing is, however, that throughout the
world, progress in this area is now being
made — in countries on the great crescent
from South Korea, Taiwan, Malaysia,
Singapore, Ceylon, India, Pakistan, Iran,
to Turkey; the northern tier of Africa from
the United Arab Republic to Tunisia and
Morocco: in Kenya; in several of the
Caribbean islands; and in a modified form
in Chile and Colombia. And just re-
cently, in some relatively favorable situa-
tions such as in Taiwan, South Korea,
Singapore and Hong Kong, family plan-
ning programs have probably brought
down the birth rate.

I hope I have given you the impression
that this is a rapidly moving field, for that
is certainly the case. Almost all the de-
velopments in national family planning
programs have occurred within the past
five years or so. Even so, there are several
qualified scholars who believe that what
is being done will fall far short of the mark
and that much greater measures must be
taken if the problem is to be met.

If I do not miss my guess, we are in the
foothills of a great world debate over the
next years on population policy itself. It
is already beginning in the United States,
as some people contend that even this
country cannot now afford a birth rate be-
yond replacement. The Planned Parent-
hood movement, historically based on the
case for the wanted child, is itself now de-
bating whether people should be dis-
couraged on social grounds from having
even the children they want. In some de-
veloping countries with relatively severe
population pressures, proposals are under
discussion with regard to the liberalization
of induced abortion, incentive programs
that would pay people for the initiation or
effective practice of contraception or for
periods of non-pregnancy or non-birth,
tax and welfare benefits and liabilities
that would work in an anti-natalist direc-
tion, shifts in social and economic institu-
tions in order to raise the minimum age of
marriage or promote female participation
in the labor force or even shake up the
family structure itself, and, finally, es-
tablishment of involuntary fertility control
in one way or another. As you can readily
see, there are great issues for mankind in
the developing debate on population
policy — political issues, economic issues,
medical issues, ethical issues. In this arena
as in others, what was taken for granted
only a few short years ago is increasingly
being called into question. In fact, it is
something of an irony that at the very
time that the United Nations, after much
travail, finally declared that the right to

22

THE MARY SCOTT NEWBOLD SYMPOSIUM

effective family planning is a basic human
right, some people are arguing that the
world cannot afford that right and that in-
dividual families must defer to the re-
quirements of the society and the state.

These problems weigh heavily on all of
us, but this is an area in which medical
people have a particular responsibility.

First, the whole field of research on the
physiology of reproduction, including re-
search on efforts to intervene in that
process, must be pursued more vigorously.
Experience with national family planning
programs in the past few years has made it
clear that the contraceptive technology it-
self is of critical importance for the success
of such programs. A difficult technology
will not work well; an easy technology is
needed. With the oral contraceptive and
the intrauterine device, the situation is far
better today than it was a few years ago;
but we are not yet near a satisfactory posi-
tion in this regard. We need more basic
knowledge of human reproduction and
more sophisticated applications to the
practice of contraception.

Medical educators also have a training
responsibility. In the United States, this
responsibility extends not only to training
the next generation of leadership for
American medicine but also a large num-
ber of students from abroad who will be-
come the medical leaders in their own
countries. To be successful, family plan-
ning programs both here and abroad must
rely upon the informed support and usu-
ally the active leadership of the medical
community. Indeed, such programs cannot
succeed, perhaps cannot even exist, in the
absence of medical enthusiasm for them.

Given these circumstances, it would
seem clear that medical education has a
major responsibility in this regard — to pro-
vide the basic training that will acquaint
doctors with the problem and enable them
to play their proper role. I take it as given
that doctors will think those things pre-
eminently medical that appear in the

medical school curriculum. Yet, to some of
us in the field, it has sometimes seemed
as though the medical profession was pre-
pared to face almost anything except the
consequences of its own success in cutting
down death rates throughout the world.

When one moves from the individual
doctor-patient level to a consideration of
the far more complicated issues involved in
the collective problem, it seems clear that
the medical schools have definite service
responsibilities in relation to family plan-
ning programs. For example, working on
the plausible assumption that at the time
of delivery women would be particularly
receptive to the subject of family planning,
the Population Council has organized the
International Postpartum Family Planning
Program, with 26 large delivery hospitals
in 20 cities in 15 countries, including the
three largest maternity hospitals in the world
and the second largest in the United States,
handling about 340,000 delivery and abor-
tion cases each year. Within the U.S., we
are now seeking to extend this postpartum
concept to programs with the American
poor. A number of medical schools have
affiliated hospitals in or near the so-called
poverty pockets of our great cities. What
could be more natural than to implement
a strong family planning and associated
maternal and child health program for the
urban poor through the facilities of our
major medical schools? Finally, the Coun-
cil is collaborating on a study with the
new International Institute for the Study
of Human Reproduction, under the dis-
tinguished leadership of Dr. Howard
Taylor, to determine what it would take in
funds, personnel, training and facilities to
develop some forms of professionalized,
institutionalized maternal care that would
reach into the rural areas of the developing
world and incorporate family planning
along with prenatal and postpartum ser-
vices.

But the overriding responsibility for
medical people is to become informed and

POPULATION AVA1 \N( III

23

stay informed on an issue with such com-
prehensive ramifications. Doctors arc not
only doctors; they are community leaders,
both here and abroad. One does not need
much sense of history to observe that the
medical profession has been largely re-
sponsible for what is without question one
of the greatest achievements of mankind—
the elimination of illness and the prolon-
gation of healthy life. Nor does one need
much historical perspective to sense that
these decades of the population problem
have placed upon world medicine, and in
a special way upon American medicine, the
heavy responsibility of exerting leadership
on the other side of the population equa-
tion. There is the challenge, and there too
is the opportunity.

(Dr. Mastroianni) Dr. Berelson has pro-
vided us with a learned discussion with
major attention focussed on the world
problem. He has pointed out that al-
though we have a variety of means which
allow for family planning, the motivation
of the individual is all important. Al-
though he espouses the concept that there
surely should be individual choice, he pre-
dicts that eventually we will come to some
system where that individual choice can be
pushed in the direction of fewer children
in the individual family unit.

Questions

Dr. Guttmacher, you stated that you
were in favor of personal free will as far
as women desiring to allow pregnancies to
go full term. And then shortly after that
you opposed abortions on demand. On
what basis do you object to them?

(Dr. Guttmacher) The American public
is not ready for it. All the polls show that
no more than 20% of the lay public is in
favor of abortion on demand and that even
less of the medical profession approves.
Thus, in the United States, abortion on de-
mand is ahead of our times. That means
we cannot hope to get such a permissive
statute. Therefore, pragmatically, I think

we ought to be realistic. Let's get a good
law, since you won't be able to get com-
plete freedom of choice. So, let us be
politicians and put before our legislatures
a humane law which some day, not too
distant, we can sell to them.

In Maryland, they've done a spectacu-
lar job. Actually, what they have done is
to remove abortion from the penal code
and put abortion under the Medical Prac-
tice Act. They have given doctors control.
The doctors elected to put into operation
the American Law Institute bill. The
medical and chirurgical faculty of the
State is allowing hospitals to interpret the
A.L.I, law according to their own light,
and therefore, a place like the Johns Hop-
kins is doing a splendid number of legal
abortions.

Rut when you have the rules spelled out
by legislators and they enforce the law as
written and abortion is not taken out of
the criminal code, it becomes a real de-
terrent to liberalization, as in California,
Colorado, North Carolina and Georgia.

In summary, I say let's above all be
realistic. I am for abortion on demand
eventually when the American public and
the medical profession are prepared for it.
First, I would like to have effective con-
traception tremendously well ingrained so
everyone will have access to it, irrespective
of marital status or age, because I think
it is far better from the physical and psy-
chological points of view to prevent preg-
nancy than to terminate it.

Therefore, let us take the time to set
the stage by having effective contracep-
tion and the introduction of sex educa-
tion in the schools. In the meantime, let's
not live under our current archaic laws;
let's- liberalize them. And when we get ef-
fective contraception and greater sexual
responsibility, then have abortion on de-
mand as a backup mechanism for failed
or omitted contraception.

There seems to be a discrepancy between

24

THE MARY SCOTT NEWBOLD SYMPOSIUM

the issue of contraception and abortion. If
you espouse the concept of freedom of
choice for contraception, why is abortion
different?

(Dr. Mastroianni) I would like to ask Dr.
Viel to comment further on this issue of
contraception versus abortion and on the
matter of induced abortion in South
America.

(Dr. Viel) I can give you the thinking of
my own country. We have the idea that
50,000 women are hospitalized because of
complications due to illegal induced abor-
tions. Out of them, five per thousand die.

I would be very glad to have abortion
on demand. It will reduce the death rate of
those young women, most of them young
mothers, and will reduce the number of
women hospitalized because of complica-
tions.

The problem is that we do not have
enough doctors to perform abortions on
demand, so if we would succeed in having
the law of abortion on demand, we will
have only one more law that, from the
practical point of view with the number of
doctors that we have, we would be en-
tirely unable to keep.

That's why, like Dr. Guttmacher, I hope
soon that we will have a contraceptive
100% effective, in order that abortion on
demand would not be necessary.

(Dr. Berelson) I won't speak about the
medical issues involved, but only about the
ethical ones. If one holds to the principle
of freedom with regard to family size and
the timing of the birth of children, there
are some people who feel that that freedom
is already effectively intervened by laws
proscribing against abortion. In fact, some-
one has recently described those laws as
constituting compulsory pregnancy for
women.

So if one holds strongly to the principle
of freedom and does not make a case
against abortion on grounds of medical
safety, then it would seem that that ethical

position ought to include whatever medi-
cal methods are available, both those of
foresight and of hindsight.

Dr. Guttmacher, what was your re-
sponse to the EROS group in California?

(Dr. Guttmacher) I told them that I
thought that, if they spent their efforts on
increasing the education of the black race,
they would probably attain political im-
portance far sooner than by sheer num-
bers.

Now, I'm not sure that's valid, but I
think there is something in that. Perhaps
I used a bad example, because I used the
example of the Jew who in numbers is
about half the number of the Negro and
still has considerably more political power.
This is due to his education and also to
what education brings, financial compe-
tence.

What improvements in contraceptive
technique can doctors anticipate in the
immediate future?

(Dr. Mastroianni) A number of groups
in the United States are working vigor-
ously on the basic physiology of reproduc-
tion. The area which has greatest promise
is not concerned with the events which oc-
cur at the level of the Fallopian tube. If
we can understand the fertilization process,
conceivably we'll be able to control it
more effectively: if we can understand
tubal transport mechanisms, with reference
to both the spermatozoa and the ovum,
perhaps we will find a means to influence
those adversely and thus to prevent con-
ception.

As has been pointed out, however, one
of the major issues is not so much method-
ology, but rather some of the other areas
which have been so well covered by our
panelists. Dr. Guttmacher has indicated,
for example, that the birth rate during
the Depression in the United States was
as low as it's ever been. And that was at

I'OITI.A I I<)\ WW \\( III

25

a time wlien we didn't have the Pill and
we didn't have the IUD. So, it's more than
a matter of methodology.

(Dr. Berelson) Of course, I would agree
that it's more than matter of contraceptive
technology. Motivation is very important
in it. I've learned over the years, or I've
tried to learn, never to talk about motiva-
tion without saying something about the
technology involved at the same time be-
cause these things are so interwoven. A
difficult technology can be utilized, but it
takes a very great deal of motivation to do
it well. But the easier the technology, the
farther into the curve of motivation one
can cut, and in the developing world,
that's of very great importance, and it can
mean a matter of decades and perhaps
longer in reaching some "solution" of the
problem.

At the Population Council, where we
put a great deal of energy into scientific
research for a better technology, we see
very few realistic possibilities of a new
major method in the next short period of
years. We would be very agreeably sur-
prised if something came along.

We have been working very hard the
last few years on what we consider the
likeliest threshold item, a low progestin
substance. There is an oral version that is
only a step toward what we're really after,
an implant in which the same material is
put into a silastic capsule which by needle
can be put under the skin. The capsule is
so arranged that it leaks the substance out
at the proper rate over relatively long
periods of time. We are still in the begin-
ning of this effort, and if everything goes
well, and we're lucky, we might see light
at the other end in about two years. But
I do not think there is anything of a
dramatically new character that is closer
than that.

Dr. Guttmacher, in the United States
most of the legislators are men acting on a

problem peculiar to women. Now, what
eflort is being made to encourage the male
to use contraception?

(Dr. Guttmacher) Very little. You know
the answer; that's why you asked the ques-
tion. The point that you want to make is
that we ought to try to coerce the male or
persuade the male or seduce the male into
a sense of greater responsibility in con-
trolling conception.

And I agree with you. Vasectomy has
been very difficult to obtain in most com-
munities. For the first time in New York,
the Margaret Sanger Research Bureau is
starting a vasectomy clinic. They will do
vasectomies, I think, on Friday morning or
Friday afternoon — this is no advertise-
ment — just as one does ordinary medical
procedures in a clinic.

This is the first time I know of that
vasectomy has been publicly being carried
out like any other standard medical ther-
apy. We hope that this will proliferate and
that other family planning clinics through-
out the country will include male steriliza-
tion as one of their in-patient services.

(Dr. Mastroianni) Dr. Viel, you men-
tioned the concept of "Machismo," and I
wonder if you would comment on the
attitude of the South American male to-
ward a contraceptive technique for which
he would have some responsibility.

(Dr. Viel) Vasectomy in Latin America
is restricted to professional groups. I know
only professional men who have requested
it privately to doctors or clinics. In the
common market, it's very unpopular be-
cause it is very difficult to point out to a
semiliterate population the difference be-
tween vasectomy and castration.

(Dr. Guttmacher) I'd like to add that
the -Upjohn Company has a new com-
pound with which they have shown con-
siderable success in experimental animals
that seems to affect the sperm cell within
four or five days of administration, but I
think it hasn't progressed beyond this

26

THE MARY SCOTT NEWBOLD SYMPOSIUM

point. People certainly are experimenting,
looking for a male pill. Obviously, if
they're just beginning human work, it
means that it's at least three or four years
off. So I would say that a male pill may
be possible, but it doesn't seem as though
it's coming immediately. It would be a
great contribution if we could have equal-
ity in this type of birth control, a female
pill and a male pill.

(Dr. Wood) A little while ago I read a
statement that, if we were able right now
to do something to keep our population
at a very steady figure instead of having it
increase, it would bring very catastrophic
circumstances, such as having the entire
population of the country pretty soon as
old as I am. Has this sort of thing hap-
pened in Japan and Hungary, where they
have succeeded in controlling population
growth?

(Dr. Berelson) If we in the United States
were to go to replacement very quickly,
our age structure would certainly be af-
fected. As a demographer recently said, it
wouldn't be very long before the age
structure of the United States would ap-
proximate that of St. Petersburg, Florida.
He further went on to say that he used to
think thai was a dreadful prospect, but
with each passing year it had more attrac-
tion for him.

I think we have to balance off these
values. We will have a much older popula-
tion if we do go to a lower birth rate and
to replacement. Would that mean a more
conservative population? Well, by most
accounts probably it would. In the demo-
graphic field, as in every other, you don't
get something for nothing, and one of the
things you'd have to pay for a stable pop-
ulation at replacement level, assuming you
could get to it, would be a shift in the
age structure with a large proportion of
the population over 50 years old. Of
course, these are continuous variables, and

we could choose some growth, but not as
much as we have.

What is your concept of the difference
between the unborn and the born person?

(Dr. Guttmacher) That is a very per-
sonal judgment to make; it comes through
one's mother's milk, religion and many
other factors. The Catholic religion feels
sincerely that it is murder to interfere with
even the four-celled egg. Interference with
conception at any point is murder to the
Catholic.

I have a different point of view. I don't
see how anyone can judge which is correct.
It is a matter of philosophical attitude; it
is nothing one can prove by either a
computer or a test tube. My attitude is
that the early ovum is a collection of un-
differentiated cells. They then begin to
differentiate; they then begin to potentiate
into a human being. But I cannot believe
that you can equate a foetus which simply
has a potential for human life and has not
lived independently of its mother with the
killing of an individual who has been
born and has had an independent life, and
therefore, I do not feel that abortion at
this stage is murder.

But I'm quite willing to say that I may
be wrong and the Catholic point of view
may be right. But I want them to say
with equal sincerity that they may be
wrong and I may be right, because I don't
think either of us can tell who is right and
who is wrong. This is a matter incapable
of proof. It is simply a matter of one's
ethos and the way one thinks, and, to me,
people born on the earth have tremendous
priority to people yet unborn.

(Dr. Berelson) This is of course a very
central question, that is, the point at which
you define life as beginning. If, for ex-
ample, one is to define life as beginning
with conception as against pregnancy — if
by conception one means the fertilization
of the ovum, and by pregnancy the im-

POPULATION AVALANCHE

27

plantation of that ovum in the only en-
vironment in which it can live — this be-
comes an important philosophical or theo-
logical differentiation in practical terms
for those who think that the IUD has its
mode of action in the intervening days.

What strikes me as very interesting in
Catholic theology is that Catholic doctrine
does not take an absolute prohibition
against the taking of human life — for ex-
ample, just wars and defense against the
unjust aggressor. But Catholic doctrine
does come very close to having an absolute
prohibition against the taking of unborn
human life.

It's interesting to inquire into how that
should be, because a priori I should have
though it ought to go the other way.

Free will is not compromised by being
subordinated to social need by some form
of legislation. We see the effect of this in
Other fields where we demand that some-
one prove that he's able to drive before we
issue him a driver" s license, and we at
least ask people to prove they're healthy
before we issue them a marriage license.
Can this not be a governmental require-
ment that a license be taken out to have a
child, and that this license is non-re-
newable except by certain conditions, and
can this be an effective means of birth con-
trol? Of course, I cannot say what would
be the punishments for those who circum-
vent it, but these problems could be
worked out. But I wonder if this could be
a practical means of dealing with the
problem in the future?

(Dr. Mastroianni) Dr. Berelson, will you
comment on the matter of free will and
on the idea that an individual should get
some stamp of approval by some govern-
ment agency indicating his competence to
be a parent before being allowed to pro-
create?

(Dr. Berelson) There are two questions
involved. One is, could this be done? I

don't think that one can say that logically
it could not be done. We do license for
other things, and logically we could for
this. I don't think we could politically to-
day, or what I can see as the foreseeable
future in this country. However, theie
would be great administrative problems
involved if one were to do that, or try to
do that.

The second question is whether one
ought to try to do this in order "to solve
America's population problem." I would
be very strongly against this. I don't think
that the problem today in this country
calls for a solution so drastic. That violates
my personal values about this enterprise,
and I personally think that it's far better
to try to solve such great human prob-
lems in which millions of people are in-
volved through the process of information
and education. Beyond that, I think that
if you don't get an informed and educated
public to understand the reasons for sik It
a drastic measure, you couldn't operate on
it anyway.

So that I am far more inclined to trust
to informed judgment, informed not
simply about the consequences for the in-
dividual family but about the conse-
quences for the total community, and I'm
prepared to take my chances with in-
dividual judgment because the alterna-
tives seem to me to be far worse.

(Dr. Guttmacher) I agree with every-
thing Dr. Berelson said. I would much
rather have this amount of energy ex-
pended on trying to eliminate and oblite-
rate our ghettoes and the underprivileged
type of American life that 23% of our
population leads.

We have seen the birth rate fall auto-
matically with an increase in education.
It's always interesting to me that the
smallest family is achieved by the Negress
or the black woman who has gone to
college. I've forgotten the figure. It seems

28

THE MARY SCOTT NEWBOLD SYMPOSIUM

to be she achieves 1.3 children; I believe
that the smallest American family.

Well, this simply means that if you can
raise the standard of living and raise the
educational horizons of underprivileged
Americans, we shall see birth rates come
down extraordinarily, probably not much
more than replacement levels.

I would like to make an all-out effort
on making birth control available, but be-
fore it's going to be accepted extensively
by a large segment of the population, we
must improve their way of living. This is
where the concentration of effort should
primarily be made.

(Dr. Mastroianni) Our time is up. On
behalf of the panel, I should like to thank
Dr. Gordon French who was responsible
for the organization of this facet of the

activities of The College of Physicians of
Philadelphia. I should also like to thank
Dr. Wood, President of The College of
Physicians. Finally, as chairman, I should
like to thank the members of the panel
who have brought to us their collective
wisdom in such an extraordinary way.

REFERENCES

1. Puffer, R.: Las Condiciones de Salud en las

Americas, 1961-62. Publicaci6n Ciendfica No.
104, Washington D.C., 1964.

2. Faundes, A.: Expcriencia en Poblacion San Gre-

gorio. Primer Seminario Brasilero de Planifica-
ci6n Familiar. Londrina, Brasil, 1968.

3. Urlanis, B. Z.: Marxism and Birth Control. Con-

gress of the International Union for the Scien-
tic Study of Population. Sydney, Australia, 1967.

4. Zambra, G. and Cabrera, R.: Experiencia de

Planificaci6n Familiar en el Area Central de la
Ciudad de Santiago. To be published.

Life and Health Insurance Today: A Survey for
the Practicing Physician*

Introductions

FRANCIS C. WOOD, M.U., President, The College of Physicians

of Philadelphia

THEODORE H. MENDELL, M.D., President, Philadelphia
County Medical Society

Chairman

VAUGHAN P. SIMMONS, M.D., Vice President and Medical Director,
The Fidelity Mutual Life Insurance Company

Participants

GERALD D. DORMAN, M.D., President-Elect, American
Medical Association

PAUL L ROBINSON, M.D., Vice President and Chief Medical Director,
The Metropolitan Life Insurance Company

WILLIAM A. SODEMAN, M.D., Scientific Director, The Life
Insurance Medical Research Fund

JOSEPH C. WILBERDING, LL.B., Executive Secretary, Medical
Information Bureau Executive Committee

D. SERGEANT PEPPER, M.D., Senior Medical Director, Connecticut
Mutual Life Insurance Company

ALBERT L. LARSON, M.D., Vice President and Chief Medical
Director, The Travelers Insurance Company

R. ROBERT TYSON, M.D., Chairman, Medical Economics Committee,
Philadelphia County Medical Society

ROBERT S. PRESSMAN, M.D., President, Pennsylvania
Society of Internal Medicine

WALTER A. REITER, JR., M.D., Vice President and Medical Director,
The Mutual Benefit Life Insurance Company

ARTHUR E. BROWN, M.D., Vice President and Medical Director,
New England Mutual Life Insurance Company

(Dr. Wood) Ladies and gentlemen, we of Physicians, and we hope you will enjoy

welcome you this morning to The College looking around this fine old building with

• A symposium presented by the Section on Pub- its museum and paintings. We are glad to

lie Health, Preventive and Industrial Medicine of

The College of Physicians of Philadelphia in co-
operation with Philadelphia County Medical So- Reprint requests may be addressed to Vaughan
ciety and the Association of Life Insurance Medical P. Simmons, M.D., Vice President and Medical
Directors of America at The College of Physicians Director, The Fidelity Mutual Life Insurance Com-
of Philadelphia, 18 January 1969. pany, Philadelphia, Pensylvania 19101.

29

30

A SURVEY FOR THE PRACTICING PHYSICIAN

see you here. I shall now ask Dr. Simmons
to proceed.

(Dr. Simmons) Thank you very much,
Dr. Wood. It's a real pleasure to be able to
greet you as Chairman of the Section on
Public Health, Preventive and Industrial
Medicine of The College of Physicians.
This program, as you know, has been
sponsored by the Section, by Philadelphia
County Medical Society and by the Asso-
ciation of Life Insurance Medical Directors
of America. The Philadelphia County
Medical Society will be represented offi-
cially here this morning by its President,
Dr. Theodore H. Mendell, the 108th Chief
Executive of this organization.

(Dr. Mendell) Thank you, Dr. Simmons.
I want to greet you officially and welcome
you on behalf of Philadelphia County
Medical Society and its 4,000 members.

This hall and this building represent
part of Philadelphia and United States
history. While talking about history, I
might mention that the first life insurance
company which was incorporated in North
America was established in Philadelphia in
the late 1700's.

Clinical medicine is very much indebted
to life insurance medicine for its very
valuable contribution in statistics. The
practicing physician is a sort of partner to
insurance because he looks after the physi-
cal health of the patient, and insurance
looks after the economic health. You can-
not separate either of them.

I am especially pleased to be here, Dr.
Simmons, and I want to congratulate you
on arranging this excellent symposium.
Judging from my meager knowledge of
life insurance, even after having prac-
ticed for thirty years and having com-
pleted hundreds of insurance forms, I am
going to learn a great deal, and I think
everybody else will. I want to thank you
for inviting me.

(Dr. Smimons) Thank you very much,
Dr. Mendell. I wish to bring to you also
the greetings of Dr. Francis Mathewson,

President of The Association of Life In-
surance Medical Directors of America and
Medical Director of the Great-West Life
Assurance Company of Winnipeg, Mani-
toba, Canada. Dr. Mathewson regrets his
inability to be with us this morning, but
he noted that our program was well repre-
sented by past presidents of the Associa-
tion, three of whom will officially be on
the program this morning and another
will substitute for one of our scheduled
speakers who is not able to be with us.
Three Past Presidents on the program are
Drs. Robinson, Pepper and Larson. Dr.
Whitman Reynolds, also a Past President,
will substitute for Mr. Joseph C. Wilberd-
ing.

Our topic for this symposium — "Life
and Health Insurance Today" — is a timely
one on the local, national and interna-
tional scenes. All of us are intimately in-
volved, be we physicians or laymen.

A similar meeting, a "Congress on Medi-
cine and Insurance," sponsored jointly by
the American Medical Association and the
Association of Life Insurance Medical Di-
rectors was held last June in San Francisco
in conjunction with the annual meeting of
the American Medical Association.

It is through such assemblages and dis-
cussions and via the printed word as the
aftermath that we hope to foster better
understanding of the problems we face as
individuals, as communities and as a na-
tion and, through this understanding,
achieve cooperation and meaningful solu-
tions.

To this end, we have assembled in this
room today the finest talent on the subject
available anywhere in the world.

Organized medicine, practicing physi-
cians and doctors of medicine specializing
in the field of insurance have gathered to
tell us the nature of their work and the
problems that we face mutually and to
create the climate of understanding neces-
sary to move forward.

LIFE AND HEALTH INSURANT! IODAV

31

The Stake of Private Medicine in Life and Health Insurance

(Dr. Simmons) Philadelphia medicine
has been doubly favored this week, first by
Dr. Dwight Wilbur, President of the
American Medical Association, who spoke
at Dr. Mendell's inaugural dinner, and to-
day by the President-Elect of the Ameri-
can Medical Association.

Dr. Gerald D. Dorman was born in
1903 in Beirut, Lebanon, where his father
was a Professor and Dean of the School of
Medicine of the American University. He
received his bachelor's degree from Har-
vard in 1925 and his medical degree from
Columbia University in 1929. Following an
internship in surgery at St. Luke's Hospital
in New York City, he engaged in private
practice as a surgeon from 1932 until he
entered the Army as a Field Surgeon in
1912. Having been commissioned as a
Captain, he rose to Lieutenant Colonel
while on active duty and, in 1963, retired
from command of the 307th General Hos-
pital and the Army Reserve with the rank
of Colonel.

From 1945 until June 1968, Dr. Dorman
served successively as Assistant Medical
Director, Medical Director, and as 2nd
Vice President and Medical Consultant
for the New York Life Insurance Com-
pany. He has served the American Medi-
cal Association as Chairman of its Com-
mittee on Workmen's Compensation, as
Eastern Co-chairman of its Physicians
Committee on Radio, Television and
Motion Pictures, and as a member of its
Medical Military Affairs, Insurance and
Prepayment Plans and Health Care Fi-
nancing committees.

Dr. Dorman is a Past President of the
Medical Society of the County of New
York and has held various high offices in
his State Medical Society.

He was a Delegate to the American
Medical Association from the Medical So-
ciety of the State of New York for six
years before his election to the Board of
Trustees in 1960 and continued in this

capacity until he was named Presidcnt-
Elect of the American Medical Association
in June 1968 by the unanimous vote of the
American Medical Association House of
Delegates.

Dr. Dorman will be installed as the
American Medical Association's 124th
President during the annual convention in
New York in July of this year, and we are
indeed pleased to have him here to speak
to us on the subject, "The Stake of Private
Medicine in Life and Health Insurance."

(Dr. Dorman) It's always a pleasure for
me to come back to Philadelphia because,
although you hear what a foreigner I am,
having been born in the other end of the
world in Beirut, Lebanon, my maternal
grandfather's family whose name I bear
with the middle "D" in my name — the
Dales — of Philadelphia, were here before
the Revolution, through the Revolution
and for many a year thereafter. So I feel a
sort of nostalgia in coming back to the
Philadelphia area.

When I was invited to be with you on
this occasion, the subject I was asked to
discuss was "The Stake of Private Medi-
cine in Life and Health Insurance."

It was a pleasure for me to accept the
invitation on that basis because medicine
and insurance are subjects with which I
feel quite comfortable.

I have been a physician for a good many
years, which qualifies me to see much of
medicine's point of view. I also have spent
a good many years as Medical Director for
the New York Life Insurance Company,
which makes it possible for me to see that
industry's point of view.

It is not only important, it is virtually a
necessity that medicine and the broad
field of insurance and prepayment draw
closer together in the months and years
ahead. We have a community of interest
that demands a close, mutually under-
standing relationship.

As a matter of fact, in these days of

32

A SURVEY FOR THE PRACTICING PHYSICIAN

constantly multiplying demands for medi-
cal and health care, I do not think it
would be in error to consider members of
the insurance industry and of the pre-
payment programs as actual parts of the
health care team, since it is health insur-
ance and prepayment that often make it
possible for the ailing and the injured to
receive the medical care they need.

Whatever else might be said about either
the differences or the relationships be-
tween medicine and insurance, certainly
both have ultimate goals that are identi-
cal. That unified goal is the well-being of
the people they serve.

Primarily, the physician is concerned
with the physical well-being of his patients.
Primarily, insurance is concerned with the
economic well-being of policyholders or
members. But, as all of us know, there are
many overlapping aspects of these con-
cerns.

Insurance also is vitally interested in
the physical health of its clients, just as
physicians are equally concerned about the
economic situation of their patients.

That latter point is particularly true in
today's highly inflated economy, in which
the cost of medical and health care has
been rising steadily and apparently will
continue to rise because of a great many
factors that are outside of the control of
either the medical profession or the in-
surance carriers.

It is, in fact, stated policy of the Ameri-
can Medical Association that physicians at
all times should be aware of the economic
factors of the services they provide and the
services they order. That consideration is
in addition to their awareness of the sci-
entific aspects of those services.

In keeping with that policy, AMA Presi-
dent Dwight L. Wilbur, in his report to
the House of Delegates last month at the
Clinical Convention, cited eight ways we
physicians can and must help hold down
the cost of medical and health care.

I would like to repeat for you, briefly,

those eight points, with some elaboration
of my own here and there.

First, we can avoid hospitalizing any
patient unless it is absolutely necessary.

Second, we can reduce the length of
stay in the hospital to the absolute mini- |
mum consistent with good care.

Third, to help implement the first two,
we can make more use of extended care
facilities, nursing homes and home care
services, as well as participating in the
expansion of all of those effective and less
expensive sources of care.

Fourth, we can stimulate prepayment
mechanisms on a voluntary basis and en-
courage all insurance carriers to provide
comprehensive coverage for out-of-hospital
services, including those that are required
both before and after hospitalization.

A possible option, offered by Dr. Wil-
bur for consideration, is the recent action
of National Blue Shield. And you can see
here that it is almost impossible to talk
about health care without talking about
insurance and prepayment.

National Blue Shield has called for all
of its member plans to make available a
"paid-in-full" program of services based on
physicians' usual, customary and reason-
able fees. The plan is to include charges
made in the physician's office, for labora-
tory and radiological tests, for care in the
home, for care in extended care and nurs-
ing home facilities, and for many other
specified services.

I think this is an option that should be
available.

Fifth, of the eight points, we can en-
courage our patients and their families to
carry adequate health insurance or pre-
payment coverage.

Sixth, we can support the principle of
income tax credits for health insurance. I
shall have more to say about that subject
later on.

Seventh, we can encourage wider use of
reliable, automated laboratory procedures,
passing the cost benefits on to patients.

1 111 AM) 111 Mill IVSI K \\( I I ODAV

Eighth and last of the president's points,
we can maintain charges for physicians'
services on the basis of usual, customary
and reasonable fees, a concept that was
defined by the House of Delegates last
month, as you know.

Accompanying this must be effective
self-discipline and peer review to consider
the fee charged and the appropriateness of
the service rendered.

If I may elaborate a little on that point,
1 should like to recall to your attention
the AMA's "Guidelines for Establishing
Medical Society Review Committees.'' The
guidelines were first published in a 1965
issue of the Journal of the AMA and have
been updated periodically since that time
as amendments were made by the House of
Delegates. The latest of those were re-
corded from the Annual Convention of
last year.

I don't want to take your time to review
in detail those fairly lengthy guidelines.
But I would point out, as a reminder, that
they include provisions:

. . . for broad representation of all fields
of practice and medical specialties in the
community;

. . . for prompt settlement of cases pre-
sented to avoid dissatisfaction and loss of
confidence in the committee's value;

. . . for adequate publicity so that both
the profession and the public know of the
committee's function;

. . . for continuity of membership in the
committee to assure consistency in decisions
rendered in all cases, regardless of the
source of the complaint or question;

. . . and finally, the guidelines call for
consultation with representatives of health
insurance and prepayment plans in order
to achieve maximum results.

Among the ways to help reduce the cost
of medical and health care to the patient,
I mentioned the AMA's concept of income
tax credits to help defray the cost of health
insurance premiums.

That idea was accepted by the AMA

House at its meeting in June of 1968. Last
month the House not only reaffirmed its
acceptance, but resolved to promote vigor-
ously the enactment of federal legislation
"that would translate into law the concept
of income tax credits for health insurance
premiums."

The report on that subject was from the
AMA Board of Trustees' Committee on
Health Care Financing. I have the privi-
lege of serving that committee as chairman.

The committee report pointed out that
adequate health care should be available
to all who need it and that methods of
financing health care must be found to
help everyone get the care he needs.

Income tax credits for the premiums
paid for adequate health insurance are an
effective way to encourage maximum par-
ticipation in voluntary, comprehensive
health insurance programs.

People who don't earn enough to pay
income tax, or who pay only a small
amount, would be given vouchers for the
purchase of health insurance.

Adequate programs would be available
from insurance and prepayment carriers
and people who buy them would be eligi-
ble for a tax credit for the premium paid.

For example, if a family owed $500 in-
come tax, and the premium for adequate
health insurance was $350, the tax pay-
ment could be $150 plus the receipt for the
insurance premium.

As health care costs continue to rise,
which we can be certain will happen, we
who are in medicine and/or insurance
must more clearly demonstrate the effec-
tiveness of the private system of medical
care and of the voluntary health insurance
mechanism.

Otherwise, I think we can expect to see
government moving more deeply into die
health care field, sometimes using the in-
creasing cost as a reason and sometimes
motivated by the lack of availability of
immediate care.

I hope that we can expect not only a

34

A SURVEY FOR THE PRACTICING PHYSICIAN

new climate, but a better climate, with a
new administration and a new congress
taking over this month. I think we can ex-
pect to see less of a continuing push for
greater welfare programs just for the sake
of welfare.

However, we cannot expect the present
government — or any government this
country might have in the future — to ig-
nore problems that generate a great deal
of public outcry. This congress and this
administration, like any before them, will
act in what they interpret to be the best
interests of their constituents and the na-
tion.

If they believe gaps exist in the provi-
sion of medical and health care to all citi-
zens, or in the ability of vast numbers of
people to afford the kind and amount of
care they need, we can expect govern-
ment action to fill those gaps. We can ex-
pect it, that is, if the private sectors of
medicine and insurance are not clearly
making progress in doing the job.

With respect to health insurance and
prepayment coverage, we must work to-
gether to make them more effective, to
make their coverage more widespread, to
make their benefits more comprehensive
and to make their protection available as
economically as possible.

We must believe and, much more im-
portant, we must prove that government
financing alone is not the answer to the
provision of adequate, comprehensive
health insurance for the people of this
nation.

I would like to dispel one cloud that
has drifted onto the horizon and led some
people to take a pessimistic view of the
future of voluntary health insurance and
prepayment. These people say that the
cause of voluntary coverage is lost since the
government has already stepped in with
Medicare, Medicaid and its many other
programs. They say the government will
one day take over completely the financing

of health care and, consequently, the con-
trol of it.

I would like to point out that similar
predictions of doom were heard from in-
surance companies back in 1936 and there-
after when social security was passed and
went into effect.

At that time there were cries on all
sides that there was no further need for
private life insurance and certainly no
need for retirement programs, since the
government was going to provide every-
thing people would need in their old age.

What actually happened? The truth
turned out to be the exact opposite of the
predictions. Life insurance has never en-
joyed as much growth as it has in the
years since 1936. The same is true for the
growth of retirement insurance, company
and union pension programs and all
other private mechanisms for providing
for one's old age and for the security of
one's survivors.

The reason, as we look back, is fairly
obvious. The establishment of the govern-
ment's social security program did not
make available every benefit everyone
could want. It was a step.

But more importantly, it called nation-
wide attention to the need for preparing
for retirement and putting aside some-
thing for the golden years. When people
realized the need for future security, they
did not try to do away with the govern-
ment program. But they rushed to take ad-
vantage of private programs that would of-
fer them even more.

1 am optimistic enough and, I think,
realistic enough to expect the same thing
to happen to voluntary health insurance
and prepayment, in spite of, or even be-
cause of, government health care pro-
grams.

Federal interest and Federal action in
health have called attention to the need
for good health care and for advance fi-
nancing of health care as nothing else has
been able to do.

LIFE AND HEALTH INSURANCE TODAY

35

And I believe we can count on the
public to want more and better coverage
for tbeir medical and health expenditures.

All of us, and all of our colleagues, must
work together to urge people to protect
themselves and show them how to do it.
We must help them understand that it is
insurance that makes it possible eco-
nomically to do what needs to be done
medically.

We must realize, of course, that in this
respect we are concerned primarily with
those people whose economic status is
above that of the indigent. For the un-
fortunate who live in poverty, medical
and health care is available now and al-
ways has been available.

Just as those people are unable to pay
for medical and health care, they also are
unable to pay for adequate health in-
surance protection until a system comes
along such as the AMA's proposed income
tax credits.

But they will be cared for, under govern-
mental or private programs, just as they
always have been cared for by individual
physicians.

The great appeal of insurance and pre-
payment is to people above that economic
level who normally are self-sustaining but
who do not have the resources to cover the
expense of a major illness or accident. For
these people, prepayment in any of its
many voluntary forms can remove the fi-
nancial deterrent to necessary medical and
health care.

That same principle applies all the rest
of the way up the economic ladder,
through the whole great middle class and
even into the wealthy group whose mem-
bers find it well worth-while to provide
themselves with adequate insurance cov-
erage rather than using their considerable
means to be self-insured.

Insurance makes it possible for the
physician to provide or prescribe diagnos-
tic and therapeutic care of the very best
type and in whatever quantity is needed

without putting an undue financial bur-
den on the patient or his family.

That will become even more true when,
at our urging and with our cooperation, the
insurance industry moves forward to ex-
tend more protection by allowing payment
for diagnostic examination or therapeutic
treatment without confinement in a hos-
pital, by paying for services in the out-
patient department, in the physician's office
or in the patient's home or an extended
care facility.

Existing programs of insurance and pre-
payment too often make patients insist on
going to the hospital because that is the
only way they can get any financial reim-
bursement, even though perfectly good
care could be provided in some other en-
vironment.

I hope, too, that before long the insur-
ance industry and the prepayment plans
will expand their coverage to include pre-
ventive medical care. That is a move which,
in the long run, I sincerely believe would
actually save money for the insured in-
dividual and for the carrier. It would avert
the need for much more expensive thera-
peutic treatment after an illness develops
that could have been overcome quickly if
it had been caught early enough through
routine, preventive examination.

As a final point, in this brief discussion
of a very far-reaching subject, I would
like to add that health insurance is by no
means the only type that helps the physi-
cian and his patient.

Retirement insurance and disability in-
surance both provide a vitally important
financial lift to many persons.

That is particularly true of disability
coverage, which many persons are wise
enough to purchase while they are healthy
and working. For people who have not
taken advantage of such protection, an en-
forced inability to work — especially for a
breadwinner — can be a financial diaster
as well as a physical and emotional prob-
lem.

A SURVEY FOR THE PRACTICING PHYSICIAN

The same is true, although to a lesser
extent usually, for persons who should re-
tire for the sake of their health at age 65
or younger. If his patient is adequately
covered by insurance, the physician feels
much more free to advise retirement when
circumstances warrant it. He knows the
patient can follow his advice and protect
his health without becoming a financial
burden on his family or even on society.

I think when we look at the field of
medicine and the field of insurance and
prepayment, it is clear to all of us that our
mutual concerns, our existing cooperation
and our need for further cooperation far
out-weigh any minor differences there
might be in our philosophies, outlook or
personal interests.

Certainly medicine and the insurance
industry are partners in both life and
health. If an obvious illustration of that

What's Going on in the

(Dr. Simmons) Our next speaker this
morning will be Dr. Paul I. Robinson.
Dr. Robinson was born in Waltonville,
Illinois, on September 15, 1904. He re-
ceived his B.S. degree from Washington
University of St. Louis in 1926 and was
graduated in medicine from the Washing-
ton University School of Medicine in 1928.
This was followed by training at the Army
Medical School in 1929 and a succession of
postgraduate courses too numerous to men-
tion.

During the course of his military ca-
reer, Dr. Robinson served as Commander
of the Fitzsimmons Army Hospital from
1951 to 1954 and was Surgeon for the 8th
Army in Korea in 1954 and 1955. He was
subsequently Commander of the Letterman
Army Hospital and later Executive Di-
rector of the Dependents' Medical Care
Program from 1956 through 1958. He is the
holder of the Distinguished Service Medal,
Legion of Merit and Oak Leaf Cluster,
the Philippine Medal of Merit and the
Korean Taiguk Medal as well as an Alumni

partnership is needed, we can find it in the
more than 20 million dollars contributed
to medical research through the Life In-
surance Medical Research Fund.

And I see no lessening of that partner-
ship, as long as both of us continue to ful-
fill our responsibilities, with physicians pro-
viding and directing health and medical
care for the people of this nation and
with the insurance industry helping to
reimburse patients for the cost of the care
they receive.

Working together, all of us can help pre-
vent physical problems from becoming
economic tragedies for millions of people
and for our country as a whole.

(Dr. Simmons) Thank you very much, Dr.
Dorman, for this illuminating and authori-
tative presentation of what is going on and
for the many suggestions which you have
offered for our benefit.

Health Insurance Field?

Citation from Washington University of
St Louis. Dr. Robinson retired from the
United States Army with the rank of Major
General.

He is a Fellow of the American College
of Physicians, the American College of Pre-
ventive Medicine, the American Public
Health Association and the New York
Academy of Medicine. He is an Honorary
Fellow of the American College of Hospital
Administrators. In addition, he is a mem-
ber of the New York State Hospital Review
and Planning Council and is a consultant
to the United States Department of Health,
Education and Welfare on matters relat-
ing to physician participation in Medicare.

He has published numerous articles on
personnel matters, hospital administra-
tion, health insurance and various aspects
of the costs of medical care.

It is a privilege to have Dr. Robinson
with us this morning to speak on the sub-
ject, "What's Going on in the Health In-
surance Field?"

(Dr. Robinson) It is a great privilege to

I.I I K AND HEALTH INSURANCE TODAY

37

be here to talk on this subject. I shall have
to tell you that I believe that my talk is
going to emphasize a number of things
that Dr. Dorman has already said.

I'm sure that all of us in the insurance
industry and all of us in the medical pro-
fession would like to know what is going
to happen to health insurance. There are
movements in several directions which may
enable us to understand what is going on
now and possibly to prophesy what the
future holds in this field.

Senator Ribicoff is said to be developing
a program for covering the uninsured seg-
ments of the population by use of subsidy
from public funds.

The American Medical Association's
Committee on Health Care Financing has
proposed a program to provide coverage
for the uninsured and to improve the
adequacy of insurance coverage for the re-
mainder of the population. This proposal
would utilize income tax incentives and
government subsidies.

Governor Rockefeller of New York has
proposed to the Ribicoff Committee a
program of compulsory health insurance
with suitable subsidies. He had proposed a
similar program a year ago. The same basic
idea is also incorporated in a study en-
titled, "Problems in Medicaid" by the
Advisory Commission on Intergovernmen-
tal Relations.

The United Auto Workers has proposed
an all-inclusive compulsory health insur-
ance program.

I. S. Falk of Yale University made a pro-
posal for compulsory health insurance at a
meeting of the American Public Health
Association in November 1968.

Walter P. Reuther, President of the
United Automobile Workers, announced
at the 96th meeting of the American
Public Health Association that a Commit-
tee for National Health Insurance has
been formed, chaired by himself, vice-
chaired by Dr. Michael E. DeBakey and
having such other members of prominence

as Mrs. Mary Laskcr and Whitney M.
Young, Jr. He announced that the Com-
mittee will launch an educational program
and "draft legislation to accomplish the
Committee's purposes and press for enact-
ment by the Congress."

The position of the Nixon Administra-
tion concerning these matters is not now
known, but we probably must concede that
the pressures are sufficient to require seri-
ous consideration of health problems.

One cannot think in terms of health in-
surance without considering the increase in
cost of medicine and hospital service over
the past several years. Many efforts are
being made to establish guidelines, if not
standards, for medical care. Determina-
tions of necessity for medical service, qual-
ity of medical service, length of hospital
stay, reasons for repetitive medical visits,
efficiency with which medical care is ren-
dered, both in hospital and out, are repre-
sentative of these efforts. Fiscal controls
have been devised and are in use, such as
physician fee schedules, hospital payment
formulae, contractual arrangements be-
tween providers and insurers, prepaid
group practice plans combining financing
and rendering of medical care, deductibles,
coinsurance, internal limitations of one
type and another, to mention several.
None has been successful, in the opinion
of many, because they have shifted the
burden of additional payments to patients
or to charitable organizations. Frequently
the excess cost has been absorbed by in-
dividual members of the profession. Cur-
rently the trend is toward payment of
physicians in accord with their own usual
and customary charge, if reasonable. Rea-
sonable determinations are made in an
ill-defined manner by payers, some using
average fees in a locality, others compari-
son of fees with previous ones submitted
by the same physician, and still others
using the latter method, provided the fee
falls within 90 percent of the average of
all physicians' fees in the locality. The

38

A SURVEY FOR THE PRACTICING PHYSICIAN

physician's usual fee is determined by
questionnaire survey or by actual study of
fees submitted and on record in the payer's
files.

The demand for medical care has been
influenced by many factors. Good food,
cleanliness and reduction in work stresses
have gone hand in hand with vaccines,
antibiotics, antihistamines, better anesthet-
ics and improved surgical techniques in
both increasing and decreasing the quan-
tity of medical care desired by the people.
While infectious and contagious diseases
have reached a reasonable state of control,
chronic degenerative conditions have come
more and more to the forefront and now
require a greater quantity of medical and
technical skills than ever before, both in
detection and treatment.

The goal of good health for all mem-
bers of society is unquestionably in the
public interest and can be supported by
providers of health care, industry, labor,
insurers and government. This statement is
greatly oversimplified because of the enor-
mous complexities inherent in getting all
to work together in an organized program
which will preserve free enterprise and yet
provide quality health service for all the
people. The situation is a mixture of per-
sonal and group attitudes toward life it-
self. The complexities not only involve
procedures, practices and behaviors grow-
ing out of expanding knowledge of disease,
mental illness and disability, but also
economic and social problems relating to
organizing and educating people to pro-
duce goods and services under a system of
adequate compensation for their contribu-
tions. In order for all elements of our
society to work together toward a common
goal of good health for everybody, more
understanding of all the problems must be
available to all.

Transferring all the responsibility for
the health of all the people to the Federal
government does not seem to be a viable
solution. The Federal government has for

many years operated large medical care
programs which from time to time have
been found to be wanting, and changes
have been accomplished by the free enter-
prise medical profession. On the other
hand, government has developed a medical
care organization consisting of prompt,
always-available medical care, rapid trans-
port to the type of medical facility re-
quired and specialty care of unquestioned
stature, some counterpart of which is badly
needed in our free enterprise system.

Those opposing the government's entry
into the medical care field have been un-
yielding in a number of general policies,
such as: 1., opposition to compulsion; 2.,
government subsidies; 3., use of general
revenues and 4., extension of present gov-
ernmental programs, such as Medicare and
disability coverage. Yet no one opposes the
premise that everyone is entitled to neces-
sary health care regardless of the means of
payment therefor.

While everyone must concede and recog-
nize the tremendous developments which
have been made in the last 25 years in
private insurance as well as government
programs of health care, it cannot be
denied that gaps and inequities still exist.
Because of the goal of good health for
everyone (which is undisputed), there is no
doubt that there will be in the next few
years many meetings, congresses, commit-
tees and conventions in which solutions
will be expounded. Many of the long-
existent policies on all sides must be com-
promised or attenuated.

It would be impertinent of me to pre-
dict what will come about or how it might
be accomplished, but certainly all the
activities I have briefly reviewed would
point to: I., more complete benefits for
those covered by health insurance and 2.,
extending the same benefits to the unin-
sured by some means which undoubtedly —
in the early stages at least — must be under
government subsidy.

The extension of benefits must be con-

LIFE AND HEALTH INSURANCE TODAY

39

Structive. Those controls which have been
shown to increase costs by forcing people
Into the hospital for diagnostic examina-
tions and trivial care must be eliminated
or modified. Many of the built-in limita-
tions should be excluded. More health
services — dental, drugs, psychiatric, reha-
bilitation and preventive services — are
desired. It is my sincere belief that the
people want such a system and that they
will somehow find the means to pay for it.
It is my hope and belief that people who
work can be provided with almost com-
plete health insurance coverage in the free
enterprise system. It will recpiire com-
promises and concessions as well as as-
surances on the part of providers of health
care and health insurers to accomplish
this. There will always be an uninsured
group. Those who have permanent un-
correctable impairments probably will

have to be cared for by government; others
who have capabilities should be provided
witli rehabilitative training and medical
care until they can be converted into pro-
ductive individuals.

In a word, it would seem that health in-
surance will in time cover more and more
of the population and will provide greater
and greater benefits, that there will be a
great struggle during the next few years to
delineate what can remain in the free en-
terprise system and what must be provided
by government, that the providers of
health care and the financiers will revise
some of their staid policies and practices to
meet the needs of the times, that there will
be developed an organization for more
efficient delivery of medical care, and that
government will more clearly outline and
define its obligations so that the free enter-
prise segment can proceed to develop in
the health insurance field.

The Life Insurance Medical Research Fund

(Dr. Simmons) Our next speaker this
morning is Dr. William A. Sodeman, a
native of Pennsylvania, who received his
basic education in the public schools of
Toledo, Ohio. He holds both the Bachelor
of Science and the Doctor of Medicine
degrees from the University of Michigan,
the latter having been received in 1931. In
addition, he holds the honorary degrees of
Sc.D. from Villanova University and
L.H.D. from Jefferson Medical College.

He has an illustrious background from
which I can select only a few major items.
From 1941 through 1946, he was Professor
and Head of the Department of Preven-
tive Medicine at Tulane University School
of Medicine. He was then named Professor
of Tropical Medicine and Chairman of the
Department of Tropical Medicine and
Public Health, a position which he held
from 1946 to 1953. From 1953 to 1957, he
was Professor and Chairman of the Depart-
ment of Internal Medicine at the Uni-
versity of Missouri School of Medicine. In

1957, he came to Philadelphia to become
Magee Professor of Medicine and Head of
the Department of Medicine at Jefferson
Medical College. He became Dean and
Professor of Medicine in April 1958 and, in
February 1962, Vice President for Medi-
cal Affairs. He remained in this post until
June 30, 1967, at which time he became
Scientific Director of the Life Insurance
Medical Research Fund at Rosemont,
Pennsylvania. He is a member of numer-
ous boards of trustees and is author of the
monograph, "Pathologic Physiology,"
which has been translated into the Portu-
guese, Italian, Spanish, Serbo-Croat, and
Japanese languages. He has contributed
192 articles to medical literature.

In addition to being a member of the
Philadelphia County Medical Society and
The College of Physicians, he reports
annually to the Association of Life Insur-
ance Medical Directors. Thus, he repre-
sents ail three sponsors of this morning's
symposium.

40

A SURVEY FOR THE PRACTICING PHYSICIAN

It is a pleasure for me to introduce Dr.
William A. Sodeman who will address us
on "The Life Insurance Medical Research
Fund."

(Dr. Sodeman) It isn't often that one
participates in a discussion sponsored by
three groups and at the same time is a
member of all three. I appreciate it very
much. I came to Philadelphia 12 years ago
and joined The College of Physicians at
that time. From that time until now, when
I enter this building, with its atmosphere
of dignity and stateliness, I get the kind of
feeling one experiences when he enters one
of the old cathedrals of Europe. And then
when one enters this Hall and sees in the
portraits on the walls such people looking
down at him as Weir Mitchell, Benjamin
Rush, William Osier, Dunglison and
Gross, one really develops this feeling of
awe and respect. I think it's easy to un-
derstand why an organization such as the
Life Insurance Medical Research Fund
had its beginnings, and had its prime
champion for its beginnings, in a city
with the kind of medical background
possessed by Philadelphia. Although many
people participated in the development of
the Life Insurance Medical Research
Fund, it was Albert Linton, President and
then Chairman of the Board of the Provi-
dent Mutual Life Insurance Company here
in Philadelphia, who was the moving force
in the discussions to create this Fund in
1940 and in its final establishment in 1945.

We've heard this morning that the first
insurance group in this country was estab-
lished in Philadelphia and again I can
say that this Research Fund, for this in-
dustry, was established here as well. At the
time, there were about 500 life insurance
companies in the United States. There are
now about 1,700. At the time, there was
little in the way of governmental activity
in research. The Federal budget for re-
search in medicine was only several million
dollars. The establishment of the Fund, by
an industry, to look into the problem of

health and particularly into those diseases
shortening life was a very important and
very fundamental approach. And it has
continued to be so. Since that time, of
course, the government has evolved an or-
ganized approach to research to such a
great extent that it has overwhelmed all
other funding in this country. Since 1945,
the Life Insurance Medical Research Fund
has put $25 million into research. The
Federal government has put, as you know,
well over S500 million yearly into compar-
able activity. Many of the NIH programs,
which run up close to a billion dollars, are
not all basically for project research.

One would think, then, that a fund
such as our own, which was established for
and does support research projects related
to biomedical problems, might add very
little at present to what goes on in research
in this country with its dollars but a drop
in the whole pot of money that exists. But
this isn't true, and it isn't true for several
reasons. In the first place, we have within
the insurance industry some very dedicated
people who help keep the Fund in perspec-
tive. This is true of the medical directors
who participate in Fund activities. Here
today, we have Dr. Paul Robinson, who
just talked to us and is just retiring as one
of the Medical Directors' representatives
to the Fund. Dr. Sergeant Pepper, who is
here, is in the same group. Dr. Thomas
Sexton and Dr. Albert Larson, both of
whom are here this morning, are others.
These men supply an input into the Fund
from the medical components of the in-
dustry not only for review but for comment
on and help in the maintenance of the
Fund in its proper perspective. This is very
helpful. Then, too, if our funds are to be
utilized effectively, since we have only
about a million and a half a year, we must
be selective in the projects chosen. We
must use this money strategically to help
people in research so that we are not
merely adding our component of money to
the same programming coming out of

LIFE AND HEALTH INSURANCE TODAY

41

Bethesda. By strategically picking pro-
jects in the utilization of this money, we
have accomplished this purpose. One of
the examples is the fact that the Fund, as
small as it is, has supported five individuals
who have become Nobel Prize winners.
Anybody can support a Nobel prize win-
ner after he gets the prize, but, when a
group in its selection of people does this
five to ten years before that time, you can
see their evaluations are done effectively.
This work is done through a mechanism
which is very very efficient, through an
Advisory Council which meets once a year
to select for support those requests consid-
ered promising out of the programs sub-
mitted. From its very beginning this
Council has been manned by those highly
respected in medical education and re-
search activities in the academic commu-
nity. At the present time we have on this
Council such individuals as James Wyn-
gaarden whom many of you in Philadel-
phia know from his activities at the
University of Pennsylvania as well as at
Duke. Until recently, Carl Moore, Pro-
fessor of Medicine and Head of the Depart-
ment of Medicine at Washington Univer-
sity was our Chairman. That position now
falls to C. R. Park, who is Professor of
Physiology at Vanderbilt. The Council in-
cludes David Bates of McGill, Frank Dixon
who is a research pathologist at La Jolla,
Robert Forster, Professor of Physiology at
the University of Pennsylvania, Donald
King, who is Professor of Pathology at the
College of Physicians and Surgeons at
Columbia, Donald Seldin, Professor of
Medicine at Texas Southwestern, Richard
Egdahl, Professor of Surgery at Bos-
ton University, Albert Lehninger, Hans
Neurath and Emil Smith, Professors of
Biochemistry at Johns Hopkins, Washing-
ton University and UCLA respectively. It's
this kind and this level of academic com-
petence which has brought about the
utilization of these funds very effectively.
The Fund has two other programs aside

from support of projects in research. We
have an activity which we call a Medical
Scientist Program. In this activity individ-
ual students in schools of medicine in this
country and Canada, chosen by their medi-
cal schools, may be put up for selection by
our esteemed Advisory Council to enter
into a program leading to both the M.D.
and the Ph.D. degree. These programs
stimulated by the Fund now are beginning
to evolve in many medical schools. There
have been some pilot programs supported
by the National Institutes of Health, but
this program has not evolved very effec-
tively as yet. We have at the present time
131 individuals in this activity in various
medical schools in this country and
Canada. Anybody can support a student in
medical school and it's fine if they do so,
but those of us who have worked in medi-
cal schools (and I was in the dean's office
for 10 years, which is twice as long as the
average) know that anyone who enters
medical school today can find, through
federal and private sources, the support he
needs, even if he doesn't have much in the
way of personal financial backing. Conse-
quently, one ought to do something more
than this if he has limited funds. And we
have done so, selecting those having po-
tential in research and medical education
to develop in them a background in in-
vestigative methods as they evolve in both
the M.D. and the Ph.D. programs to be-
come educators and to become basic in-
vestigators in biomedical research. You
might say we are drawing people from
practice when we do this, but let me point
out to you two things: first, this is a small
group and those going into research in
medicine represent only 5 to 8% of those
in medical schools at the present time. Our
program isn't increasing this component;
it is making some of these individuals
sounder individuals when they go into
their chosen activities. Second, in the
manpower problems we have today and
the need to expand the medical schools, we

42

A SURVEY FOR THE PRACTICING PHYSICIAN

need people of this type. Therefore, this
program which was started by the Fund
represents one of the important tech-
niques the Fund has of implementing pro-
grams in fundamental areas which nobody
else is considering. This has been a very
effective approach and one can see in most
of the medical schools across the country
that this idea is catching on with money
obtained from other sources to carry
through with it. Of the 131 individuals we
have chosen, some of them have left our
program at a time when they could get
funds from other sources. But their goals
have remained established. Out of the 131,
we have had only five individuals not
measuring up to their goals, that is, who
have decided not to do biomedical research
and not to teach. They wanted to go into
practice. In only five of the 131 has this
happened, and I think this is a good
record.

The Fund has one more program, our
so-called third program, which is just
evolving at the present time. This activity
has to do with some of our country's major
problems. We've heard about the man-
power shortage this morning. I am very
concerned about it and serve on Dwight
Wilbur's Council on Health Manpower
at the AMA. All of us who are interested
in this problem know that it isn't a num-
bers game only, that we have our problems
not only of having more individual physi-
cians to lead health teams and having more
allied health personnel but, in addition,
we have deficiencies in techniques for
delivery of health care. This problem has
been established by any number of groups:
by the AMA in its approach, by the
President's Commission on Health Man-
power and by many others. We have num-
bers of our citizens who never gain entry
into our health care systems satisfactorily.
And we need methods to correct this.
These problems have not been taught ef-
fectively and have not been approached
effectively in the medical schools. They

require individuals who have background
in areas other than the basic medical
sciences. Preparation is not for bench re-
search, not for the kind of research the
biochemist does. Consequently, their back-
ground in basic science must be of another
kind. It must be in economics, in political
economy, in chronic epidemiology, and in
a number of related areas. We have very
few people trained in medical sciences and
in these fields as well. Those who manage
the Fund, that is, the members of the
Board of Directors who represent the in-
surance industry, felt that this area re-
quired an effective program, in which we
could choose and train individuals who
have status on their own medical school
faculties, who have the desire to do this
kind of work, who have already reached
status in one of the divisions of medicine
(whether this be internal medicine, pedi-
atrics, surgery or whatever it is) and who
plan to enter into a research program of
this sort. There are now many departments
of community medicine in medical schools,
but many of these are set aside from the
rest of clinical medicine. Because penetra-
tion into the community in this kind of
program is extremely important, partici-
pants must relate with status to the clinical
departments. If we take individuals of the
sort who have this interest and we fund
them in partnership with the school so that
they will evolve in that school to teach
students and do research in these areas,
they will have an influence on other mem-
bers of the faculty, influence upon the
students and an impact on delivery of
health care within the medical center as
well as outside the medical center. We will
have developed in this way a focus in
strategic places in this country for the de-
velopment of this research. As you can see,
we put our money again in men; we put
our money where we get the most out of
the small amount of money we have; we
develop men who have an influence for a
generation. In turn, these individuals can

LIFE AND HEALTH INSURANCE TODAY

43

obtain project research money from other
sources. But you must have those who
know what to do to ask for such project
money. This is the basis for the third pro-
gram of the Life Insurance Medical Re-
search Fund. It is just starting. We have
made only one grant thus far and that was
a month ago. It was made to the University
of Rochester School of Medicine in the
Department of Medicine to Dr. Paul
Griner, an Associate Professor of Medicine
there. We plan to set up several more
projects this year. We think the program
is very fundamental.

You can see that the Life Insurance
Medical Research Fund, although it has
restricted money, utilizes those funds in a
very effective and efficient way so that it
strategically can get the most mileage out
of its dollars not only for the Fund and for
the industry, but for the good of the
health of the country. We need more
money as everybody in research needs
more money, and we do have plans for
greater participation of the industry.
Those of you who have read the report of

the President's Commission on Health
Manpower saw several significant state-
ments there. One is that this total prob-
lem, with all the tax money that the Federal
government has, is too big for the Federal
government alone. This means that private
sources in all areas, whether from founda-
tions that are independent completely,
whether from areas supported by various
groups and various industries, or whether
from various other segments of society,
have a very important part in inter-re-
lating to supplement and complement the
total funding in health research in this
country in the most efficient way that it
can be done. We think that the Life Insur-
ance Medical Research Fund and the life
insurance industry, through the Fund, is
accomplishing this.

(Dr. Simmons) Thank you, Dr. Sode-
man. The Life Insurance Medical Re-
search Fund has done fine work over the
years and is continuing to do so under
your leadership and we are very fortunate
to have a person of your caliber to provide
this impetus to the work.

The Medical Information Bureau

(Dr. Simmons) The next presentation
was prepared by Mr. Joseph C. Wilberding
who received an A.B. degree from Yale
University in 1934 and an LL.B. degree
from Columbia in 1937. He was associated
with the New York law firm of Bleakley,
Piatt and Walker from 1937 to 1939.
Following this, he joined the Legal Depart-
ment of the New York Life Insurance
Company where he remained until 1947
except for service in the United States
Army. In 1947, Mr. Wilberding became
Executive Secretary of the Medical Infor-
mation Bureau and has continued in this
position since that time. He has served
with distinction in this post and has be-
come well-known and well-loved by the
medical directors and lay underwriters
with whom he has w r orked over this long
period of years.

Unfortunately, Mr. Wilberding has been
stricken with the flu and is unable to be
with us. However, we do have a copy of his
paper and, in view of the importance of
this subject, it will be read by Dr. Whit-
man M. Reynolds, 2nd Vice President and
Medical Director, Bureau of Insurance
Medicine of the Equitable Life Assurance
Society of the United States.

(Read by Dr. Reynolds) It is my part of
this program to talk to you regarding the
organized exchange of medical information
between the medical directors of life insur-
ance companies. The organization respon-
sible for this activity is called the Medical
Information Bureau and I am its Execu-
tive Secretary.

I feel sure that most of you, over the
years, have realized that some sort of in-
stitutionalized exchange of information

44

A SURVEY FOR THE PRACTICING PHYSICIAN

occurred between life insurance compan-
ies. However, since we have seldom gone
out in the world to publicize or explain
our work, I am afraid there is a fair
amount of misunderstanding about our
activities.

In recent years we have tried to dispel at
least some of this misunderstanding by
talking about the Medical Information
Bureau openly and frankly in the insur-
ance business. However, this meeting today
is the first time that I have talked gen-
erally about the Bureau outside the con-
fines of the insurance world.

Now I don't expect to dispel any in-
grained prejudices, in this brief talk, but I
do hope that as a result of what I have to
say, most of you will feel that the Medical
Information Bureau is a reasonable system,
that it was founded to meet an obvious
need, and that it has been organized so as
to protect the reasonable interests of all,
including those persons who apply for life
insurance, honestly and in good faith — in
other words, many of those "forgotten
people" mentioned in our last election.

My approach will be along these lines:

First, I should like to describe what I
see as the nature of the underwriting proc-
ess in the case of ordinary life insurance.
This, I believe, will indicate the reasonable
need for an information exchange.

Second, I shall describe the nature of the
exchange, what information goes into it,
how it is handled, and what limitations are
put on its use.

And, finally, I would talk very briefly of
the future, and a possible contribution
that this exchange may make to medical
research, going beyond its present life
underwriting function.

Now as to the nature of the life insur-
ance underwriting function. Here, I think
there are three points. These are simpli-
fied, and underwriting is, of course, a
complicated subject about which far more
can be said. These points are, however,
basic and they do relate to our Bureau.

First, please don't think of life insurance
as simply a series of business corporations,
merchandising, through persistent agents,
a product whose sale sometimes results in
profits and sometimes in losses — but where,
in either event, the results, good and bad,
are picked up by stockholders. This is
simply not the case.

Fundamentally, life insurance is a group,
or groups, of people who have gotten to-
gether to share the cost of a predictable
hazard — death. Perhaps better stated, they
are groups of people who have been as-
sembled through the efforts of life insur-
ance agents to share together the cost of
the hazard. The agent is the catalyst who
brings people together in their own inter-
est, rather than the driver who forces
people to buy a product.

Now many of the people, who join to-
gether in these groups, go a bit further and
use life insurance as a means of cash
saving, as well as a sharing of the cost of
the hazard. The benefit of mass saving is,
of course, another reason for the purchase
of life insurance, but it is not the funda-
mental basis of the arrangement. You
can save on a mass basis at a savings bank
or a mutual fund, but only if life insurance
is involved can you cover the risk of death.

It is from these groups of people, in
their sharing of the risk, that most of the
funds come to pay off the contracts. It is
true there is investment income (and there
is also agency and company expense), but
by far the greater portion of the money
involved is contributed by the policyhold-
ers as premiums, and most of it goes to pay
the beneficiaries. This is where the money
comes from; this is where most of it goes.
Inasmuch as most of us own life insurance,
life insurance is "us," not "they."

A second underwriting point is absolute:
every applicant for life insurance will die,
but it is impossible to say exactly when
for any individual. It is, however, possible
to foretell to a remarkable degree, through
statistics, that a certain number of any age

LIFE AND HEALTH INSURANCE TODAY

45

group will probably die, from some cause
or another, within any one year. There-
fore, sooner or later, in the absence of lapse
in payment of premiums, he or his heirs
will be collecting his share of the group
kitty.

The basic question to be decided when
the individual applies for life insurance is
how much he should pay into his group
each year, in order to contribute his fair
share to the predictable death benefit pay-
ments that will fall due each year. If he
doesn't contribute his fair share, some
other policyholder, somewhere, will make
it up.

Now remember, he has designated what
he wants as his share at the time he enters
the group. In other words, when he ap-
plied for life insurance, he designated the
face amount of the policy. These face
amounts can run from five hundred dollars
to over sixteen million dollars on one life,
and they may provide for payment of
premiums — or contributions to the kitty —
over extended periods of time, one to
fifty or more years. There may be a lot at
risk in the case of one individual.

This is where the medical underwriter
comes in. He must make the decision as to
I what group the applicant belongs in and,
in effect, how much premium he should
pay in order to make his fair contribution
to the group. And if the premiums have
| not been properly calculated, or if too
I many poor longevity risks have been ad-
mitted to the group, and numerous early
I losses have occurred, then it is likely to be
I the remaining policyholders who will, di-
rectly or indirectly, make up the funds to
pay these losses.

The underwriter has certain tools to
help him. For instance, he has a standard
mortality table showing the probable
longevity of groups of individuals, based
1 on age. This is the basic life insurance
tool, and with it the underwriter can figure
out the necessary premiums, using age
alone, if he can assume that the amounts

at risk will be uniform, at a relatively
small level, and that all his applicants are
in an average state of health. Rut not
everyone who applies is in good health, or
even an average state of health, and, as
previously indicated, the applications can
be in varying amounts, even up to the
previously-mentioned sixteen million dol-
lars. So the underwriter must go further
than just determining age before admitting
an applicant to the group; he has no alter-
native but to try to find out the state of
health of the applicant. And remember,
the applicant has opened the door to such
an inquiry by applying for life insurance.

There are two situations when this need
is apparent:

1. Where the applicant is in truly bad
health and has minimal prospects of
even the shortest longevity. Here, for
this individual to make an adequate
contribution to cover his fair share of
the risk, such a large payment would
probably be required that the policy
would be unattractive to him. Prob-
ably also there would be very few per-
sons similarly situated who would
wish to purchase life insurance at
such a cost, and thus you would not
be able to form a group, and remem-
ber, group sharing of the risk is the
basic principle of our business. These
people are, therefore, usually consid-
ered uninsurable. It is interesting to
note that the life insurance business
has whittled away at the number of
situations that it considers uninsur-
able, so that now only approximately
2 to 3 percent of ordinary life appli-
cations are not accepted. Higher mor-
tality groups are being assembled and
risks are being taken in so-called "ex-
perimental" cases. From the experi-
ence with these cases, it is hoped that
further mortality groups can be de-
veloped on a basis that will be attrac-
tive to many risks usually considered
uninsurable.

46

A SURVEY FOR THE PRACTICING PHYSICIAN

2. Where there is some health history
that indicates the individual does not
belong in a standard mortality group.
Over the years, the life insurance
business has made statistical studies of
many aspects of health history. I feel
sure most of you are familiar with the
build and blood pressure studies. It
has been clearly shown that the mor-
tality rate for some such groups ex-
ceeds the standard rates. However, it
is also possible to insure these people
for life insurance by calculating what
this extra risk is and requiring higher
premiums. In such an event, if
enough of them are insured, they will
make an adequate contribution to the
kitty so as to be able to be acc epted for
large amounts. This is usually referred
to as substandard or extra risk issue,
and, although only 6 percent of the
number of policies issued in a repre-
sentative year (1967) were substandard,
the volume at risk was quite large. For
instance, in 1967, over six billion
dollars of extra risk ordinary life in-
surance was issued, and the total
amount of such insurance in force at
the end of the year was over thirty
billion dollars.
The presence of an adverse health his-
tory is thus a vital factor in the under-
writing of about 9 percent of the applica-
tions.

But the ability to obtain adverse health
histories is not only of assistance to these
cases; it is also an assurance to the under-
writing of the remaining 91 percent of the
cases which are accepted standard.

In situations where there is an extra,
but acceptable, risk, the underwriter must
see that such individuals are placed in
groups that pay an extra premium for the
extra hazard. I would emphasize that the
medical underwriter does not make a medi-
cal diagnosis; he simply tries to group in-
dividuals with like individuals in the same
statistical group, so that all will make their

fair contribution to the pool. There is a
difference in the two decisions, and it is
one that is sometimes misunderstood by
the public. This point will be mentioned
by others here today.

The underwriter has a lot of choices of
various boxes (or groups), in which he
may put the various extra-risk applicants,
and he may have a lot, or only a little,
medical information. There is no doubt,
however, that the more and the better
medical information he has, the better
and fairer decision he can make.

Naturally, companies in our business
take different attitudes towards different
impairments. Although, as previously
stated, statistical studies of impariments
are available, they are usually of past his-
tories, and their use must be tempered by
knowledge of the advances of medicine.

The action of the companies will differ
on many occasions as a routine matter.
The point is that they must be able to
make informed judgments in order, basi-
cally, to see that each policyholder makes
a fair contribution to his group. And to
make an informed judgment, the medical
underwriter must have the maximum
amount of medical information reasonably
available to him.

Now, there is a third point relating to
underwriting which is more sociology than
medicine or insurance. I would mention
that among applicants for life insurance
there are the forgetful: they don't remem-
ber that hospital visit three weeks ago.
There are the dupes: they let the broker
fill out the application. And there are the
outright cheats: people who are willing,
ready and anxious to have someone else
accept their burdens.

Fortunately, there are really not too
many of these bad eggs in the world, and,
despite what you may hear and feel, I am
informed by many underwriters that the
situation in regard to this type of dis-
honesty is not discernibly worse than it
was thirty years ago. Still and all, it is

LIFE AND HEALTH INSURANCE TODAY

47

obvious that for any business that is ac-
cepting large risks with other people's
money, some steps must be taken to guard
against the deprivations of the dishonest.

Experience indicates that where an in-
dividual has applietl to one company and
has been declined or rated, he is more
than anxious to secure some life insurance;
and at this point, when he comes to an-
other company, knowledge of prior find-
ings may be especially valuable where
there is an effort to defraud.

It therefore seems obvious that the medi-
cal underwriter must have available to him
medical histories and histories acquired by
other insurance companies in connection
with applications for insurance should be
especially valuable. This is the reason for
the existence of the Medical Information
Bureau. Insofar as the industry has ac-
quired any previous knowledge about an
individual, on his subsequent application
; for further insurance the new medical
underwriter will have at least some signal
as to what has been previously found.

Now what is the nature of this exchange?
The Medical Information Bureau is an
unincorporated, non-profit trade associa-
tion. It now has over seven hundred
members, in both the United States and
Canada. Each of these is a life insurance
company and each must be so qualified
within the definition of the United
States Internal Revenue Laws. Each mem-
! ber has a locally-licensed physician serving
as Medical Director. Both the member
company and the Medical Director, as an
individual, must sign a pledge that the
rules and principles of the organization
will be followed.

The Bureau was founded in 1890 by
the Association of Life Insurance Medical
Directors and until 1947 was operated as
a function of that organization. In 1947
the Bureau was reorganized as a separate
institution to be governed by an Executive
Committee of nine company officers. Four
of the members are medical directors, four

are company senior officers other than
physicians, and one is a general counsel.
This committee is responsible for the
management of the Bureau.

Reporting Procedures

Naturally, lines must be drawn as to
what information is required to be for-
warded to the Bureau by the members.
The Executive Committee has done this
by adopting a so-called List of Impair-
ments. This list covers a broad spectrum
of health conditions and other factors
that could be of some significance to the
home office underwriters.

If a member company, in considering
an application, or even preliminary in-
quiry, finds one of these conditions, then
that company is pledged to report such
information in brief, three-digit, form to
the Bureau's central office. These entries
are made daily by member companies, and
each separate condition is indicated by a
code number. The Bureau handles up to
nine thousand such entries a day.

The new entries are correlated with in-
formation already on file and made avail-
able thereafter to any member company
who has received an application or in-
quiry or claim from the individual. The
members check the names of all ordinary
life cases with the Bureau records and
information may be found, depending on
the company, in 5 to 40 percent of the
cases submitted. Periodic studies by mem-
bers indicate that substantial mortality
savings result from checking cases through
the Bureau.

Sources of Coded Information

The Bureau receives these entries of
coded information only from its members.
There are no outside sources of informa-
tion. The Bureau has no employees who
go out to investigate or examine individ-
uals. All information is provided by the
members.

The members do not indicate whether

48

A SURVEY FOR THE PRACTICING PHYSICIAN

an application has been declined or rated
or postponed or accepted. They also do not
state the amount of insurance applied for.
In sum, the underwriting evaluation of a
case is not reported to the Bureau.

The members simply send in the codes,
which will give a general idea of the sig-
nificant medical or non-medical facts they
have learned. By having this information
available, underwriters thereafter will
know that past problems existed when a
subsequent application or inquiry is re-
ceived.

Most applications ask questions concern-
ing any record of previous applications,
and there are, of course, other ways
whereby a company can sometimes find out
the underwriting action of other com-
panies, if this is thought to be necessary.
They cannot, however, learn this through
the MIB; company action is simply not
shown in the Bureau's records.

Maintaining Accuracy

Great stress is laid on identity, accuracy,
and correctness in submitting and print-
ing reports. The Bureau follows a series
of checking procedures aimed to produce
correct copy. Very seldom does a printer's
error, or mistake of identity, occur. Avoid-
ance of this type of error is not an easy
task, because the Bureau's service office is
not given the key to the symbols; the work
of printing and editing must be done
without knowing the meaning of what is
being handled.

It should be noted that all MIB infor-
mation is not of a debit or negative nature.
Frequently, the codes will indicate the
results of favorable tests, and this should
help in placing the risk if further applica-
tions are submitted. For example, favor-
able EKG's and X-rays are reported and
also the results of favorable glucose toler-
ance tests. The presence of a report of such
a test will often expedite underwriting.

If an impairment has been reported
present by a company and on subsequent

examination, by the same company or by
another, it is found no longer present, then
the Bureau's rules require that this fa-
vorable result should also be reported to
the Bureau. This is sometimes referred
to as "clearing the record." By "clearing,"
it is not meant that the old information is
eliminated. What is left, after such an
entry, is both the old and the new infor-
mation. Although it very rarely occurs, if
information shows that the old entry was
based on incorrect data, the reporting
company is required to correct the record.

Reporting companies are encouraged to
make available their findings to attending
physicians, on request of the individual.
Although disputes in this area can arise,
they are infrequent, possibly because we
try to handle medical matters through and
with medical people.

As to use of MIB information in the
home office, I emphasize that it is not
given to the members without limitations.
Under the mutual agreement which all
the companies are pledged to observe,
MIB information is to be used as a flag of
warning and as a supplement to the mem-
ber's own underwriting investigation for
personal insurance or claims thereunder.

Under Bureau rules, no application can
be declined, rated, or restricted solely be-
cause of an MIB entry. This does not
mean that a medical examination must al-
ways be asked for; in some circumstances
it may be an attending physician's state-
ment, or a credit report, or other back-
ground information. It does mean, how-
ever, that each member must make its own
independent underwriting investigation
and come to its own independent conclu-
sion regarding the risk.

MIB information is made available only
to the home offices of member companies
for underwriting and claims purposes. It
is not given to government or any others
outside the membership. Strict security is
demanded and observed.

This last point occasionally raises dif-

LIFE AND HEALTH INSURANCE TODAY

49

faulty, especially in highly competitive
markets. Questions are asked as to why
the Bureau insists on the secrecy of Mill
impairment entries. Why does the Bureau
go through this work of pledges, codes,
code book accounting, and all the para-
phernalia of trying to keep such a tre-
mendous body of information confiden-
tial? It is done essentially for two reasons.

First, it is a principle of confidential
information that, unless you keep it con-
fidential, your sources are unlikely to co-
operate again in the future. The insurance
business receives many items of confiden-
tial information, which are necessary to
sound underwriting. Sound underwriting
means lower costs of insurance to all
policyholders, since it insures equitable
treatment and protects the honest from the
few who try to conceal significant informa-
tion. Therefore, representing the industry,
the Bureau must protect its sources.

Second, the information developed and
maintained is primarily medical in nature.
The individual himself may not know all
the medical facts regarding his state of
health. The Bureau's constitution provides
that the MIB must protect not only the
interests of the insurers and other policy-
holders, but also the interest of the appli-
cants.

The Bureau, therefore, is in a difficult
area. It is possible that the applicant may
be suffering from a serious disease and his
physician may not have told him. It is
possible that the applicant knows he has
something wrong with him, but his busi-
ness associates do not. To protect the in-
dividual's interest, the information about
him must be kept confidential.

An individual with an MIB record will
always receive careful consideration, and
the action of one member does not de-
termine that of others. Each company is
entitled to reach its own underwriting de-
cision with all known facts in view. This
is all the MIB seeks to attain.

In the final analysis, I believe the Bu-

reau, as part of the life insurance in-
dustry, participates in a great work, I
think our business helps good people meet
their responsibilities, as individuals, in a
simple, economical manner. It would be
naive to believe that there are not some
around, who would just as soon see other
people shoulder their burdens.

The MIB makes its contribution by
trying to assure that each application will
be evaluated on the facts. The Bureau is
not infallible. Undoubtedly, there are
situations which are missed. But if the
Bureau did not exist, one of two things
would surely occur, and probably both:
either more lengthy and costly under-
writing procedures would be adopted or
mortality rates would rise sharply. In both
situations, it would be the honest policy-
holders who would be bearing the brunt
of the increased cost.

As to the future, we see the Bureau as
continuing to perform a useful underwrit-
ing function for many years to come. We
have been in existence since the 1890's; we
have moved with the times insofar as re-
organizing our procedures is concerned;
and we have been favorably examined by
state insurance authorities during the past
twenty years.

But we do not see this underwriting
function as being enough. With the future
developing use of computers, we see it as
probable that the vast storage of medical
information available to life insurance
companies (either through their life or
health insurance activities) can somehow
be made helpful to medical research. We
are not sure how, at this point, and we
are not now on a computer, but we are
hopeful, and we are working in this area
with some of the best minds in the business
consulting field.

Several research projects have already
been conducted with Bureau assistance,
and here I refer to studies of diabetics by
Dr. Goodkin of the Equitable, of EKG's
by Dr. Singer of New England Mutual,

50

A SURVEY FOR THE PRACTICING PHYSICIAN

and also of EKG's by Dr. Mathewson of
the Great-West in Canada.

As you know, medical research, medical
knowledge, and medical practice are all
moving — and moving fast. It is the intent
of our industry to play a part in some of
these matters, and we believe our Bureau
will have a good contribution to make to
this effect.

Conclusion

In conclusion, I would emphasize a
point that I have not previously made. The
basic ingredient woven into the warp and
woof of this institution is the continued
interest and guidance of the company
medical directors. We know that, if we did
not seek the highest professional standards
for the confidential care of this informa-
tion, our industry could not underwrite as
economically and as efficiently as it has.
We appreciate the cooperation that has
existed to such great extent between our
medical directors and their brethren in
the medical profession.

Finally, as a "carry-away," I summarize
the points that I have tried to make:

1. Life insurance is a device whereby
responsible people may join together
to share the burden of the risk of
death.

2. In any sharing, the burden must be
fairly and intelligently allocated;
otherwise, people would not join
therein. In large measure, the success
and growth of the life insurance busi-
ness has been a result of its fulfilling
this requirement.

3. Knowledge of prior health history is
essential to any such allocation.

4. The MIB helps meet this need, and it
is organized in a reasonable fashion
to protect the proper interests of all
concerned.

5. We see a future in which large medi-
cal data banks, such as MIB, may
become of use to medical research,
at the same time maintaining the
anonymity of the individual. We are
working to develop this possibility
and are hopeful of favorable results
which should appear in the middle or
late 1970s. We, in the Bureau and
our industry, are trying to move for-
ward with the rapidly developing
changes that are occurring both in
medicine and in the techniques of
handling tremendous amounts of in-
formation. The picture is not yet
clear, but I am optimistic as to the
future.

Clinical Versus Insurance Medicine — There Is a Difference!

(Dr. Simmons) Our next speaker is Dr.
D. Sergeant Pepper. Dr. Pepper was born
in Philadelphia on May 12, 1907. Follow-
ing his graduation in 1925 from the Haver-
ford School, he engaged in additional study
at the University of Pennsylvania and at
Franklin and Marshall. In 1932, he was
graduated from the University of Pennsyl-
vania School of Medicine. After additional
training in medicine, he was licensed to
practice in the State of Pennsylvania in
1934 and entered the private practice of
medicine in Philadelphia. He served the
University of Pennsylvania Medical School
as Assistant Instructor in Medicine and as

Ward Physician for the University of Penn-
sylvania Hospital. In 1939, he was made
Associate in Medicine and limited his
practice to internal medicine, with em-
phasis on communicable diseases.

He served with distinction in the Army
Medical Service during World War II and
left active duty at the end of 1945 with
the rank of Lieutenant Colonel. He is
now a Colonel in the Army Reserve Corps.

Dr. Pepper entered the life insurance
business in January 1946 as a staff physi-
cian of the Provident Mutual Life In-
surance Company here in Philadelphia. In
1946, he was made Assistant Medical Di-

LIFE AND HEALTH INS TRANCE TODAY

51

rector. In L952, he joined the Connecticut
Mutual Life Insurance Company in Hart-
ford as Assistant Medical Director and has
served successively as Associate Medical
Director, as Medical Director and, since
1965, as Senior Medical Director.

He was Vice President of the Association
of Life Insurance Medical Directors of
America in 1962 and President dining the
year 1963.

He is an Alumni Trustee of the Uni-
versity of Pennsylvania, a Fellow of the
American College of Physicians and a past
Fellow of The College of Physicians of
Philadelphia.

It will be of interest to this audience
that in 1950 he was elected a Delegate to
the Pennsylvania State Medical Society
from Philadelphia County Medical Society
for a two year term.

In the early 1950's, Dr. Pepper was on
the original committee that proposed and
drafted the constitution for the Board of
Life insurance Medicine. He was certified
by this Board in 1952 and became its
Chairman in 1957 and 1958.

He has been a member of the Hartford
Medical Society since 1954 and has been
its Treasurer from 1959 until the present.
He is a member of the Professional Educa-
tion Committee of the American Cancer
Society and serves on the Board of Di-
rectors of the Mount Sinai Hospital As-
sociation.

It is a pleasure to introduce Dr. D.
Sergeant Pepper who will speak to us on
the subject, "Clinical Versus Insurance
Medicine — There Is a Difference!"

(Dr. Pepper) Drs. Wood, Mendell, Sim-
mons, members of The College of Physi-
cians of Philadelphia and the Philadel-
phia County Medical Society, and guests
— I might almost say "Family," — because
my wife has been kind enough to come
here today, and I see my revered Uncle
Perry looking down upon me from the
gallery up there! I am very honored to
have been asked to appear on this pro-

gram and I'm very happy to be back here
in my native city. Although I have been
away from Philadelphia for twenty-two out
of the last twenty-eight years, I still feel
very much at home. I was a member of
both of your societies many years ago
and attended many meetings in this hall
and over at your auditorium at Twenty-
first and Spruce Streets. I don't believe I
abused the privilege of being at the po-
dium very often in those days and I trust
that I won't be too long on this occasion.

After I left Philadelphia ami went to
Hartford in the insurance business, I
found I was still close enough to Phila-
delphia so that I could return frequently
and I have been very glad to have had
that opportunity.

Although I am very pleased and honored
to be on this program with so many dis-
tinguished gentlemen, I am not happy
about the title assigned to me. I do not
know who chose it and I hope that
Vaughan Simmons will not tell me after
the meeting that I did!

However, the choice of the word "versus"
was unfortunate. The first meaning of
versus is as it is used in law or sports and
suggests a conflict of one side against an-
other. This is certainly not what we want.
The second meaning of the word is
"considered as the alternative of," as in
free trade versus tariffs. This again does
not apply, except perhaps when one de-
cides to take up insurance medicine as an
alternative to a job in clinical medicine. I
would hate to think that a seriously ill
patient might consider insurance medicine
as an alternative to clinical medicine. That
might be disastrous.

So I ask you to forget the printed title.
I want to talk about clinical medicine and
insurance medicine, their similarities and
their differences.

But first I had better give you a brief
introductory lesson in life insurance in
order that you may have a better under-
standing of the nature of our work.

52

A SURVEY FOR THE PRACTICING PHYSICIAN

Basically, insurance medical directors are
interested in long-term prognosis of dis-
ease so that purchasers of insurance may
secure financial protection against life's
uncertainties for themselves and their
families at a price that is consistent with
the risk involved.

Life insurance is like fire and casualty
insurance. The price of the insurance
varies with the risk. For example, fire in-
surance on a frame house in the country a
long distance from any fire department will
cost more than insurance on a fireproof
building with installed sprinkler system
just down the street from the firehouse.
Likewise, an applicant for life insurance
with a rheumatic mitral stenosis or diabetes
has to pay more for his insurance than
an individual in perfect health.

Up until the end of the last century,
applicants for life insurance were either
accepted at standard rates or declined.
Often the decision was made more on an
applicant's appearance than on a true
medical evaluation. In the late 1890's, how-
ever, Mr. Arthur Hunter, Actuary, and
Dr. Oscar Rogers, Medical Director, both
of the New York Life Insurance Company,
devised a numerical system by which ap-
plicants could be classified so that people
with medical impairments could be in-
sured at equitable rates. The numerical
system is based on the assumption that
healthy individuals have a mortality that
may be represented by the percentile 100,
which is equated from a combination of
height, weight, age and sex. In actual
practice, the percentile 100 is a modal
figure. Negative and positive values are
added to or subtracted from this figure.
Thus the applicants referred to above with
rheumatic heart disease and diabetes
would have a numerical addition to the
basic 100 percent. A credit, or minus
value, might be associated with a favorable
physique or with longevity in the family
history. The final classification, which is
the algebraic summation of the debits and

credits, is a percentile which represents the
underwriter's opinion of the mortality risk
in terms of a previously determined stand-
ard. In actual practice, this is but a guide
or framework. There is always an added
element of judgment.

At age 40 in normal healthy people, we
average four deaths per 1000 in the next
year, a figure which is taken from our
mortality tables. This then is the "stand-
ard" or 100% mortality. If six deaths oc-
cur, we have 150% mortality, eight deaths
200% mortality, etc. We speak of "stand-
ard" cases when the anticipated mortality
is below 130% and "rated" cases when
we expect the mortality to be above this
figure. In most companies, the standard
class runs from 85% to 130%. Substand-
ard classes may reach as high as 1000%
and rarely even higher. Most companies
have a ceiling of 500%.

In addition to the debits which are de-
termined for medical reasons, there are
debits which may be assessed for other
reasons such as occupation, hobby, morals,
habits, finances, etc. As the reasons for a
rating or declination are not always able
to be discussed with an applicant, he may
unjustly blame his misfortune on the
medical examiner or the personal physi-
cian's statement. When information,
whether medical or otherwise, is obtained
from confidential sources, we cannot, of
course, discuss the substance of the infor-
mation or the source with the applicant.

Needless to say, once a rating has been
decided upon and the applicant accepts
the policy and pays his premium, the in-
surance company cannot increase the rat-
ing no matter whether his health deterio-
rates or he decides to become an astronaut.
On the other hand, many ratings are
removed or reduced for improvement in
both medical and other conditions.

It is obvious that there must be many
similarities between insurance and clinical
medicine. We all start with the same train-
ing and have to go over the same hurdles

LIFE AND HEALTH INSURANCE TODAY

53

to be licensed to practice medicine. Many
of us have had experience in the clinical
practice of medicine before entering in-
surance medicine. In general terms, our
problems are much the same: developing
and interpreting history, physical findings
and laboratory tests in order to reach a
diagnosis.

We differ, however, in how we get the
necessary information to reach a diagnosis
and what we do once the diagnosis is
made.

In most instances, the clinician is deal-
ing with a patient with symptoms or with
an obvious disease process. The patient
wants relief and is more than willing to
cooperate in any way to help his doctor
arrive at the proper diagnosis. The physi-
cian thinks in terms of this one individual
and does his best to diagnose the trouble
and give proper treatment. He may rea-
lize that there is an immediate or even
remote threat to life, but if he is giving
the best treatment available his mind does
not dwell on the mortality significance
of the illness as he feels this is beyond his
control.

I also believe that the average clinician
thinks in terms of pathology, rather than
in terms of years of survival. For example,
in a patient with repeated attacks of
pyelonephritis, he is concerned over the
development of chronic pyelonephritis and
eventual kidney failure. He visualizes the
progressive kidney damage and does all he
can to prevent it, but he does not think
of this disease process in terms of the
average number of years of life remaining.
After all, rarely can one predict the course
of disease in any one patient and, perhaps
in a year or two, the outlook will change
and a more accurate prognosis can be
given.

In life insurance medicine, we deal with
applicants who are presumably healthy.
This is borne out by our statistics which
show that 90% of applicants for life in-
surance are issued standard policies. The

other 10% have some significant medical
history or some medical condition at the
time of application. Less than 2% are de-
clined, and the remainder are either issued
a rated policy or fail to complete their
application. The latter, perhaps 3%, are
probably scared off by the prospect of
paying a large extra premium or of having
to undergo some further medical examina-
tion requested by the insurance company.

Our medical histories come to us from
thousands of examiners based in every
state across the country. Our medical his-
tory forms are familiar to many of you.
The questions are stereotyped and very
general in nature. The applicant feels no
compulsion to give any more information
than necessary. We are dependent upon
our examiners to develop points of in-
terest. The illness or operation that may
be of importance is often two or more
years prior to the date of the examination.
As you well know, the human mind tends
to forget the unpleasant facts of illness
and to recall only the favorable ones.

This is why it is just as important for
us to obtain records of former illnesses,
details of surgical procedures and patho-
logical reports of removed tumors as it is
for you in your care of a new patient. Not
all patients are told that they have had
cancer, and not all patients are given an
accurate account of their blood pressure
fluctuations. Yet, I am sure, that you will
all agree that both of these facts may alter
longevity.

Our physical examinations are also not
as complete as we would prefer to have
them. Rectal and pelvic examinations arc
not required nor are ophthalmoscopic
examinations of the eye or palpation of
the peripheral pulses. Routine labora-
tory work is limited to a test for albumin
or sugar in the urine for the smaller case
and urinalysis, chest X-ray and EKG for
the larger amounts. Many of these omis-
sions are forced upon us by competition.
If one company decides that life insurance

54

A SURVEY FOR THE PRACTICING PHYSICIAN

can be written without financial risk by
omitting the rectal examination, other
companies may have to follow their ex-
ample. Life insurance agents or salesmen
learn very quickly which company has the
fewest requirements. They then take their
business to this company.

As medical directors we must review this
somewhat abbreviated history and physical
and decide whether we can approve or
decline the application. Frequently we
need further information. This may mean
a report from the personal physician, a
sigmoidoscopy, X-ray or laboratory study.
Here again we may be limited in the ex-
tent of our investigation. We can only
spend a certain number of dollars for
medical investigation per $1,000.00 of life
insurance without jeopardizing the com-
plicated premium structure. We also have
to limit our laboratory studies to those
tests that have no risk involved to the
applicant. Cardiac catheterization or coro-
nary angiography are hardly indicated.
Even the B.S.P. test is considered too risky
in many comapnies.

We have, of course, other sources of in-
formation. Dr. Reynolds, in giving Mr.
Wilberding's paper, has described the
Medical Information Bureau. While we
cannot use this information as a basis for
declining or rating an applicant, it often
gives us a check on whether the applicant
has given us an accurate history. If it does
not agree with the history, we have an
opportunity to re-examine or re-question
him in order to confirm the MIB data.
We can also review the business inspection
report that may contain items of past ill-
nesses or operations. In large cases, the
inspectors may interview the applicant or
his wife, his neighbors, business associates,
local merchants and druggists. It is sur-

Insurance Forms — Probk

prising how much medical information is
obtained.

Finally, we must classify each applicant
into a standard, rated or declined cate-
gory. After that, his individuality is lost
for he is only a part of a large cohort. 11
we have classified him correctly, it does
not matter to the company if he dies
sooner or later. The group, as a whole,
will give us the expected mortality rate.

In summary, then, physicians both in
clinical and insurance medicine are evalu-
ating much the same information in order
to treat the physical and financial troubles
of their clients. The two specialties of
medicine do have differences, however.

The clinician can follow a patient and
re-evaluate his diagnosis over a period of
time. The insurance medical directors
must reach a firm decision within a rela-
tively short time and can only change this
decision later in favor of the applicant.
The clinician has the health of his patient
and, to a small extent, his reputation at
stake. The medical director has huge
sums of money at stake. Every day he acts
on many individual lives for amounts of
$100,000.00 or more and not infrequently
lives are insured for multiples of
$1,000,000.

With these large sums, all sorts of pres-
sures are brought to bear on him to give
a standard policy or squeeze the applicant
into a more favorable class. He must steer
an accurate and prudent course, for some
very large companies, as well as small ones,
have gotten into financial difficulties
through too lenient underwriting. Too
strict evaluation is almost as bad, as this
drives business to other more competitive
companies.

Those of us who are in insurance medi-
cine find it fascinating, intriguing and in-
tellectually stimulating.

ins and Solutions: A Panel

(Dr. Simmons) The next item on the These documents have become a real
program is a panel on insurance forms, problem for practicing physicians, and

LIFE AND HEALTH INSURANCE TODAY

55

we have a panel of experts here this morn-
ing to talk about the problems and to
give us some indication of what the solu-
tions might be. They will tell us what has
been done and what is currently being
done to solve the problem. The Moderator
of our panel is Dr. Albert Larson who has
been, since 1962, Vice President and Chief
Medical Director of The Travelers In-
surance Company. Currently a representa-
tive of The Association of Life Insurance
Medical Directors to the Life Insurance
Medical Research Fund, he has also served
on committees for the American Society of
Internal Medicine, Health Insurance As-
sociation of America, the American Geri-
atrics Association and the Connecticut
State Medical Society. He is a member of
the Bureau of the International Commit-
tee for Life Assurance Medicine. He is
certified by the American Board of In-
ternal Medicine and is a Fellow of the
American College of Physicians.

Dr. R. Robert Tyson, Immediate Past
Chairman of the Standing Committee on
Medical Economics of the Philadelphia
County Medical Society and a member of
the Board of Directors, is another of our
panelists this morning. He is a graduate
of the University of Pennsylvania School
of Medicine, class of 1944, and is Professor
of Surgery at Temple University Medical
Center. Dr. Tyson is a member of the
Blue Shield Corporation and a member
of its Board of Directors. He is also a
Delegate to the Pennsylvania Medical So-
ciety.

Dr. Robert S. Pressman is an internist
and serves as Clinical Assistant Professor
of Medicine at Temple University Medi-
cal Center. He is a graduate of Temple
University Medical School, class of 1937.
He is Attending Physician, Preventive
Medicine and Infectious Diseases Section,
at Einstein Medical Centers and is on the
staff of Germantown Hospital. He is a
Delegate to the Pennsylvania Medical
Society, a member of the Insurance Re-

view Committee and the Subcommittee on
Infectious Diseases and Heart and Cir-
culatory diseases of the Philadelphia
County Medical Society. As noted on your
program, he is also President of the Penn-
sylvania Society of Internal Medicine.

Dr. Walter A. Reiter, Jr., the third mem-
ber of our panel, is Vice President and
Medical Director of The Mutual Benefit
Life Insurance Company of Newark. He
had his undergraduate work and received
his medical degree from Cornell Univer-
sity, the latter being conferred in 1947.
He practiced internal medicine both in the
United States Navy and in private practice
with a particular interest in respiratory
diseases. Until 1959, when he became
associated with The Mutual Benefit Life
Insurance Company, he had been in the
private practice of medicine. He became
Assistant Medical Director, Associate Medi-
cal Director, Medical Director and, in this
past year, Vice President and Medical Di-
rector of The Mutual Benefit. He has served
on the Executive Council of the Association
of Life Insurance Medical Directors of
America and on the Ad Hoc Committee for
a uniform Part II, the part of the applica-
tion for life insurance which is completed
by the medical examiner and submitted
as part of the application. Dr. Reiter is
currently a representative of the Associa-
tion of Life Insurance Medical Directors
to the Life Insurance Medical Research
Fund. I am happy to present this panel
to you.

(Dr. Larson) I am very honored to be
sitting in this hallowed chair. Gentlemen,
I welcome you to this panel which is un-
rehearsed and unpredictable. One of the
constant sources of irritation to the prac-
ticing physician ever since any type of
health or life insurance has been in exist-
ence has been filling out a form. Life is
getting very complicated. It makes no dif-
ference whether it's a health claim, infor-
mation regarding an insurance applicant,
a workman's compensation case, or a third

56

A SURVEY FOR THE PRACTICING PHYSICIAN

party liability case — all of these things
require forms to be filled out and com-
pleted by the physician to show evidence
of proof of a loss that has occurred for
which the individual is responsible. I see
no way to get rid of this irritation, but
1 think it might be possible to put some
lype of a salve on it which would make
it a little bit easier to live with. Our panel-
ists will speak about this.

Almost fifteen years ago, I served on the
Committee of Professional Relations of
the Medical Directors Association and
began collecting forms that were used by
companies. It was a rather interesting
undertaking because some strange things
came out. Bill McBurney, then of The
Prudential, did the same thing and, at
that time, he was connected with the In-
ternational Claims Association in an of-
ficer capacity and was able, through the
International Claims Association and the
Health Insurance Council, to achieve
some degree of uniformity in health
claim forms. Some of the questions col-
lected were quite interesting. It says here
on an old form, 1., "Describe fully how
the insured is spending his time. Does he
visit his office or place of business and, if
he does, for what purpose?" 2., "Do you
know anything from heresay or otherwise
about this claimant's character, reputa-
tion and good standing?" 3., "If the pres-
ent address is rural, give the RFD number
and the nearest trading point." These are
actual questions from forms. Another:
Has the patient or any member of his
family ever had or received treatment for
a specific disease during their lifetime?"
That's quite an order! "If you adminis-
tered any medicine to this policyholder,
what was it? How did it affect the pa-
tient? What symptoms have developed
^ince the treatment began?" And as for
the qualification of the physician, the
question was, "What kind of medicine do
\ou practice?" (Laughter.) Well, those
were some of the things that we were con-

fronted with. Now we'd like to turn the
discussion over to our panelists. Dr. Press-
man, why don't you begin with your
story.

(Dr. Pressman) I am pleased to come
before you to tell you of the internist's
approach to filling out these forms. I'd
like to say at the outset that I am more or
less of the devil's advocate when it comes
to insurance forms. I am afraid that in-
surance forms, like death and taxes, are
always going to be with us. With the ex-
pansion of insurance coverage for health
care and the increase in comprehensive-
ness, it is inevitable that the insurance
company wants to know what's going on
and to get as much information as pos-
sible. However, the other side of the coin
is that it becomes an increasing time fac-
tor in the physician's office when you have
to start processing claims for the reim-
bursement of the patients. You can have
your hands full in short order. I have
seen patients come in to my office with
as many as seven different forms following
a spell of illness that lasted three days.
The time involved is just simply tre-
mendous if you have any volume of
patients who have been sick.

What are the problems in filling out
these forms? Really, what you want to
put down is the salient data: the patient's
name, the diagnosis, the dates of treatment,
the specific service performed and the
charges. And that's really all that is neces-
sary to report for the insurance companies
to accurately know what is going on. How-
ever, there is one problem on the diagnosis
that I would like to bring to your atten-
tion, and I do hope that something can be
done about, and that is if the patient has
carcinoma. I am sure you've all had the
same experience where a patient had the
form filled out and insisted on having it
returned to him. Inadvertently, the diag-
nosis of "carcinoma of the breast" or some
other organ was put down. The patient
then went into a panic, because this was

LIFE AND HEALTH INSURANCE TODAY

57

the first time he ever realized that he had
carcinoma.

The next problem is the dates of dis-
ability. Actually, what the insurance com-
pany wants to know is when the patient
stopped work and when he returned to
work. Well, the only way that 1, as the
attending physician, can know when he
stopped work is to ask the patient. It's
obvious that the insurance company can
ask the same question and not bother the
physician, or the insurance company can
write a letter to the employer and get this
information. Not only that, the patient
can tell me anything he wants and I simply
cannot check the accuracy of his state-
ment, so what we are getting, in effect, is
second hand information that is really not
too reliable. Actually there is no diffi-
culty in policies covering surgical proce-
dures and there is no difficulty in those
covering only hospitalization. The problem
comes when the patient has disability in-
surance which covers time out of work and
then, of course, it becomes very important
for the company to know how long the
patient is actually out of work. It can be a
problem with self-employed people. I per-
sonally know a patient who was self-em-
ployed who went back to work who kept
insisting on bringing forms for me to fill
out, stating that this was perfectly okay, that
he had checked it with the agent and that
the agent said there was no objection to
this. Obviously this could not be true.

Another thing that we find objection-
able is the request for information con-
cerning other policies. Again, this is fre-
quently very difficult. We do not know of
all the policies a patient has. The only
way the physician can tell is if all forms
are presented to the physician at one
time. Then and only then is it possible
to list all the various policies.

Finally, let me agree with Dr. Larson's
point about unnecessary and irrelevant
questions which only serve to infuriate
practicing physicians and to make certain

that the insurance company is going to
get inaccurate information.

I also want to talk briefly about the
request for information concerning in-
surability. I believe that the average in-
ternist tends to be too detailed, to give
too much information. There is really onb
some brief data, I am sure, that the in-
surance company wants. In order to as-
semble this brief data, it sometimes is
necessary to do a very extensive search of
the records, and this can take a consider-
able period of time. This is especially true
for a patient that you have been creating
for a number of years. One has to find the
dales the patient was seen, the diagnosis,
lab data, X-ray reports, electrocardiograms,
etc. This can really become very difficult
I'd like to make some suggestions toward
its solution. Because of the time facto:
in making out forms, it might help to
defray the physician's costs with some
small compensation. I don't know
whether this is heresy or not, but a physi-
cian has to employ a secretary whose onl\
job is to fill out insurance forms. If the
insurance companies in some way could
help to defray the costs in these policie>
where the reimbursement is going to a
patient, this might be helpful.

I think that as far as the cancer problem
is concerned, the solution would be to
put "diagnosis on file." If the insurance
companies would accept this, then they
could write to the physician directly. He
could then send the correct diagnosis
back, such as "carcinoma of the breast."
In this manner, trouble could be avoided
and it would certainly assist in keeping
patients from getting terribly upset.

Regarding insurance policies covering
time out of work regardless of mobilit\.
it is up to the insurance companies to se;
a ceiling on the writing of health in-
surance policies and allow the patient to
collect only a certain percentage of income
to avoid profiteering on health. How this
can be done I don't know, but it is a

58

A SURVEY FOR THE PRACTICING PHYSICIAN

tremendous problem. We have seen pa-
tients who have a really tremendous
amount of health insurance and it almost
pays them to be ill. They tend to take
advantage of it and stay ill as long as they
possibly can.

If you want information about other
insurance, perhaps it might be wise to
have a central clearing house for all poli-
cies. In the age of the computer, I am sure
that this would not be too difficult. As to
the unnecessary and irrelevant questions,
it is quite obvious that they should be
deleted. As to insurability, I think it would
help if the insurance companies would
state to the internists, at least, how de-
tailed a report they want and what their
underwriting needs are. Actually, I know
very little about the underwriting needs
of insurance companies and I would ap-
preciate information as to what determines
the insurability and what are your under-
writing needs. In that way, the internist
can give a very precise and brief report.

(Dr. Larson) Thank you, Dr. Pressman.
It is not only the case of carcinoma which
presents a problem; there are also many
cases in which psychiatrists will not give
any information regarding a patient. How-
ever, on the new form, you don't have to
write down the diagnosis, but simply the
code. This is perfectly acceptable if you
happen to know what code you want to
use. I might say that this is used very
often by psychiatrists without giving any
specific diagnosis.

The question about other health cover-
ages was put in, as you realize, to cover
the problem of overinsurance. The new
form was gone over very carefully with
the Council on Medical Services of the
AMA and it is a jointly sponsored form.
If you don't know or if you don't want
to answer this question, it's perfectly all
right. Your information may help in this
new coordination of benefits program so
that we have an inkling — another source
of information — as to whether or not he

has other coverages. We do ask the patient,
too, of course.

I'd like to have Dr. Tyson continue this
discussion.

(Dr. Tyson) The progress that has been
made by the health insurance group with
uniform forms has been a great help.
However, as has already been indicated,
there are still many problems. They are
still irritating and, as Dr. Pressman indi-
cated, when you have to go back over
records, it becomes extremely irritating. I
find this happening when you have to go
back over old records for some new pur-
pose such as applying for life insurance.
I often find that I have to go back over
old records if the insurance forms come
through too late after a current illness. So
the timing is important.

I do want to go over some of the gen-
eral problems, some of which Dr. Press-
man has talked about. In the last two
days, through my office — we don't handle
a great many insurance forms — we had
nine totally different forms presented to
us. Most of these, fortunately, required
only about seven items to be answered.
However, some required up to fifteen
items to be answered. It is difficult for
secretarial help to understand the
various implications and get the proper
answers down. With all of us, our secre-
taries do most of the work and we check
and sign the forms. We are troubled with
repetitious filing. We have some patients
who come in with the same form of seven
or ten items that supposedly have to be
answered every week because the patient
is still convalescing and out of work. It's
rather ridiculous. Every now and then we
rebel and decide that we are just not going
to answer. We'll sign our name to it to
indicate that the patient is still out and
let the rest go because the answers are
really the same. We really don't have the
time to look them up again.

One of the items that touches on com-
ments from Dr. Pressman and Dr. Larson

LIFE AND HEALTH INSURANCE TODAY

59

is the fact that most of these forms are
single sheets, two sides, part for the em-
ployer, part for the doctor, part for the
hospital, and a part for the patient to
fill out. The patient usually ends up hand-
carrying this around because if he doesn't,
it becomes lost in the bureaucracy of our
hospitals. And, of course, he sees diag-
noses and everything else that goes into
it. Of course, one way to keep the patient
from getting undesirable information
about his diagnosis and other things is not
to give him that part of the form. And
although this type of an arrangement in
printing may be more economical, I would
think that some separate forms might be
devised that also might help in prompt-
ness of filing, because I can't work on a
form if the hospital has it and vice versa.

I would like to suggest further work on
uniform forms. Trying to get agreement
on one standard form would be highly de-
sirable for all of us, a form that would
require the transference of routine infor-
mation the least number of times. Is it
necessary to put down age to help in
identifying a patient if there happen to be
two members of a family? I suppose we
have to get back to using numbers to
identify people, and I suppose that some
items of this sort might be the simplest
solution provided that we have to con-
tinue filling out forms in this fashion.

I would like to suggest that there be a
central cooperative center based on a
computer, using an identity card such as
the various charge services issue, that
not only woidd store data but would
identify the individual directly from the
card. It could be done by a machine and
transcription would not be necessary. A
telephone service could telephone in the
information; coding could be done im-
mediately from the office. You could get
immediate verification in all instances
whether this particular person is covered
for this field or whether this particular
person is not covered and whether the in-

surance is applicable. One of the major
problems to be worked out with this sort
of system is how to maintain the confi-
dentiality of the information. But with
the complexity that we seem to be moving
into, I don't think there is any question
that ultimately this is the type of opera-
tion that is needed. Obviously if we are
going to maintain our private enterprise in
providing health care, we have to be able
to compete with a centralized organiza-
tion and unless we, the physicians, and all
of the insurance companies band together,
I don't see how we can provide as inexpen-
sive care as some other large central agent.

I once sat down to lunch with the ne-
gotiator for Canadian Steel Unions. We
were talking about this problem, and I
said, "Why are you so much in favor of
governmental health insurance?" He said,
"Why, this is big business. We must know
ahead of time how much it is going to
cost our members so that we can negotiate
properly in our contracts. We have to have
one central agent to deal with; we can't
be dealing with half a dozen. Do you
know any other organization that is big
enough, hires enough people and has
enough prestige to provide this?" A pretty
tough question to answer when we have
our health care fragmented the way it is.
I think we must get together.

(Dr. Larson) Thank you very much, Dr.
Tyson. I think we are all intrigued, in this
age of cybernetics, with the use of a com-
puter. In Hartford, we have been check-
ing into how this can be done. IBM is
doing this in their clinical decision support
system to a certain degree. Of course, all
we're talking about is gathering informa-
tion, and that's exactly what a computer
can do. Perhaps someday all vital statis-
tics will be on a computer. I'm not so
sure that I want this, but maybe we won't
have much of a decision as to whether or
not we will be on a computer.

(Dr. Reiter) There have been some very
significant questions posed here today. I

60

A SURVEY FOR THE PRACTICING PHYSICIAN

would like to be firm and state that we
loo realize the difficulties involved with
health insurance forms. Dr. Larson has
been one of the members who has been
very active, as have many of the other
men here at one time or another. In this
form situation, the Health Insurance
Council has done a rather massive job, as
Dr. Larson mentioned briefly, to solve the
problem. The Council has combined its
efforts with various committees within the
AMA and other insurance claims and
health associations. The answers are not
all here yet. We know that. But I think
we have made strides.

I was on a committee which put to-
gether and recommended the standard life
insurance form (Figure 1) for general use.
Already, companies are starting to use it
or an identical one, except for minor
changes. You have heard mentioned that
there are some 1,700 life insurance com-
panies in the industry. Perhaps the top 50
or 100 do most of the business throughout
the country. Every time that somebody
tries to coordinate or put together a com-
mon form which will be used by many
companies, the easier it becomes for the
physician to do the job. I will not go
nto great detail on this except to say
that this form was designed to simplify the
physician's reporting of a medical history.

Dr. Pepper has done an excellent job
in discussing the relationships between
clinical medicine and life insurance medi-
cine. Gentlemen, you must realize that
we too have the assignment to obtain a
certain amount of information so that
decisions and determinations can be made
intelligently.

Regarding the attending physician's
statement, Dr. Pressman asked a specific
question: how does one fill it out? Figure
2 is a standardized attending physician's
statement form which many companies
are using. Dr. Larson and I spoke about
this very briefly. 1 don't know whether I
can make an accurate estimate, but perhaps

90% of the life companies are using this
standardized attending physician's state-
ment form. I think we could take a lot of
time to try to answer how the physician
should fill it out. We are not asking him
to make a determination as to this man's
insurability. The applicant typically does
not know the details of his medical his-
tory and may not recall that he had some
medical care. We are interested in a sum-
mary of the pertinent points. For a general
complete physical examination, we don't
expect a complete run-down of all of the
facts and figures. A summary of the posi-
tive findings, diagnosis and treatment
would suffice. Each company represented
in this room and perhaps throughout the
country may have somewhat different re-
quirements within its own organization as
to how it would interpret the statement,
but basically we are looking for a simple
summary of the medical history.

Other forms cause the greater difficulty
for the clinician. Dr. Larson and Dr. Ty-
son mentioned the combined form recom-
mended by the Health Insurance Council
and the AMA. This is a more recent coali-
tion of the reporting of the claims, be they
major medical or disability income type
claims. The aim of the Health Insurance
Council and the AMA organizations that
worked with the insurance industry was
to produce a form which would be simple
and better than the one which we had. I
dare say that this might be simplified
further if we kept working. This appears
to satisfy better the increasing use of
electronic data processing in business ac-
counting. In this all-purpose Comb 1 (Fig-
ure 3), the components possibly could be
made more responsive to changing atti-
tudes of the medical profession. We are
still working to find better ways to solve
the physician's problem of coping with
seven to nine different forms in one day.

I'd like to ask Dr. Larson whether the
physician has the election, of using and
returning the HIC approved form?

LIFE AND HEALTH INSURANCE TODAY

61

TO THE BLANK LIFE INSURANCE COMPANY

Proposed Insured

First name

Middle miiml

Laat name

Birth Date:

Moniti

Day

Yonr

a. Name and address of your personal physician? .
(Ij none, so state)

b. Date and reason last consulted?

c. What treatment was given or medication prescrihed?-

Yes No
□ □

feet, paralysis or stroke; mental or nervous disorder? □ □
Shortness of breath, persistent hoarseness or cough,
blood spitting; bronchitis, pleurisy, asthma, emphy-
sema, tuberculosis or chronic respiratory disorder?

Have you ever been treated for or ever had any known
indication of:

a. Disorder of eyes, ears, nose, or t hroat?

b. Dizziness, fainting, convulsions, headache; speech de-

d. Chest pain, palpitation, high blood pressure, rheu-
matic fever, heart murmur, heart attack or other disorder
of the heart or blood vessels ?

e. Jaundice, intestinal bleeding; ulcer, hernia, appendi-
citis, colitis, diverticulitis, hemorrhoids, recurrent in-
digestion, or other disorder of the stomach, intestines,
liver or gallbladder?

f. Sugar, albumin, blood or pus in urine; venereal dis-
ease; stone or other disorder of kidney, bladder, pros-
tate or reprodu c tive organs?

g. Diabetes; thyroid or other endocrine disorders?

h. Neuritis, sciatica, rheumatism, arthritis, gout, or dis-
order of the muscles or bones, including the spine,
bac k, or joints?

i. Deformity, lameness or amputation?

j. Disorder of skin, lymph g l a nds, cyst, tumor, or cancer?
k. Allergies; anemia or other disorder of the blood?
E Excessive use of alcohol, tobacco, or any habit-form-
ing drugs?

□ □

□ □

□ □

□ □

□ □

□ □

□ □

□ □

□ □

□ □

3, Are you now under observation or taking treatment? □ □

4. Have you had any change in weight in the past year? □ □

5. Other than above, have you within the past 5 years:

a. Had ar.y mental or physical disorder not listed above? □ O

b. Had a checkup, consultation, illness, injury, surgery? □ □

c. Been a patient in a hospital, clinic, sanatorium, or

other medical facility? □ □

d Had electrocardiogram, X-ray, other diagnostic test? □ □
e. Been advised to have any diagnostic test, hospitaliza-
tion, or surgery which was not completed? □ □

6. Have you ever had military service deferment, rejection

or discharge because of a physical or mental condition? □ □

7. Have you ever requested or received a pension, benefits,

or payment because of an injury, sickness or disability? Q □

8. Family History : Tuberculosis, diabetes, cancer, high blood
pressure, heart or kidney disease, mental illness or suicide? □ □

Father

Mother

Brothers and Sisters

No. Living

No. Dead

Age if
Living?

Cause of Death?

Age at
Death?

DETAILS t v.- an wow (IDENTIFY QUESTION

M MMER, CIKCI.l. APPLICABLE ITEMS: Include
diagnoses, dates, duration and names and addresses of all
attending physicians and medical facilities.)

Females only: Yes No

a. Have you ever had any disorder of menstrua-
tion, pregnancy or of the female organs or
breasts? □ □

b. To the best of your knowledge and belief are

you now pregnant? fj D

(THIS SPACE FOR INDIVIDUAL COMPANY USE)

Fic. 1. The standard life insurance form.

62

A SURVEY FOR THE PRACTICING PHYSICIAN

Complaints and abnormal
physical findings

Dates attended
Month Year

Duration
of illness

Diagnosis

Describe treatment
or operation

2 Laboratory Find.rgs (including x-ray, ECG, BMR and pathological reports, etc. with dates)

3 Present condition, if known? (include sequelae and complications of above reported illnesses)

4 Have any other physicians or surgeons been consulted? II so, please give name, date, and nature of disorder.

5 Please record any other information which might have a bearing on this person's hsalth.

Form approved by
Council on Medical Service
AMA, Doc. 1959

THIS FORM MUST BE SET-IT DIRECTLY TO THE HOME OFFICE

Date „ (Signature)

M. D.

Fic. 2. The standardized attending physician's statement form.

(Dr. Larson) He does. One of the things
that we advocate is that if you get a
case such as the one you were describing
with nine different forms, it is perfectly
acceptable to utilize the Comb 1 form for
all nine. Another question that has come
up here is the question of payments. It
has been stated by the American Medi-
cal Association, as a matter of policy, if
I'm not wrong, Dr. Dorman, that no pay-
ment shall be made for the first completion
of a claim form. The government is not
going to pay for it, and the insurance in-
dustry is not going to pay for it. Now if
additional information is needed to evalu-
ate the case, then frequently we do pay
for that additional information, especially
if the doctor requests it. It has been a
policy of our Association that there should
be a reasonable payment made for infor-
mation requested for underwriting pur-

poses. I might mention in regard to attend-
ing physician's statements (which the
agents hate, I think, more than you do) the
fact that some companies are utilizing a
24-hour, seven-day-a-week telephone serv-
ice which allows you to pick up the tele-
phone any place in the United States
and call this information in and dictate it
on a tape such as we are using here.

There is a commercial which sells some
kind of new cigarettes which says, "You've
come a long way, baby I" I think we have
come a long way, but we haven't gone all
the way. We think we have to continuously
work, and the committees are continu-
ously working, on this matter of forms.
We want them to be as simple as possible
but you must realize that we have to have
certain proofs in order to pay out policy-
holders' money. We try to keep the matter
as simple as possible. The points that both

LIFE AND HEALTH INSURANCE TODAY

63

HEALTH INSURANC E CLAIM - CROUP OR INDIVIDUAL
PART A

■ I I (10 «

TO BE COMPLETED BY PATIENT (INSURED)

Spaced for Typewriter — Marks for Tabulator Appear on this Line

PATIENT S NAME AND AUDWM

DATE OF BIRT

INSURED ■ NAME IF PATIENT IS A DEPENDENT

NAME OF INSURANCE COMPANY

POUCV NUHIK

INIUHOJ MQAl SECURITY HUMMER

If OROUP insurance , name OF FOLIC V HOLDER (U§, Employer, Union ot Allocution through whom tmuttd)

AUTHORIZATION TO TAY ItNSFITS TO PHYSICIAN: I Ixrtbf autt-Ofiia
p*Tni .1 dlrertly to « u*id«r*lgned Phyiician of rh« Surgicjl and/or M«<Jk*l
■«n«fift, if arty, oWwnrf M pjyshi* to m« for hit MrvtCW M d«tcrib«d b«'ow
but not >o Ric*«d HM roaionabU And ci/ltom»ry eSarga tor thoi* ltnriew.

►

• IONED (INSURED PERSON.

AUTHORIZATION TO RELEASE INFORMATION: i hi -by a-mo/iis I he
undariignad Physician fo ril««w *r>r Information acquired in ths court* of
my eiemlnjtion of tr«»fmtnt.

SIGNED (PATIENT. OR PARENT IF MINOR)

PART B

ATTENDING PHYSICIAN'S STATEMENT

t. DIAGNOSIS AND CONCURRENT CONDITIONS

(IF DIAGNOSIS COOK OTHER THAN ICOA* USED. GIVE NAME I

2. IS CONDITION DUE TO INJURY OR SICKNESS ARISING OUT OF PATIENT'S EMPLOYMENT I

V„ □ NO □

pregnancy t

:. □ no □

IF YES. APPRO 1 1 MATE DATE
PREGNANCT COMMEKCCO.

DATE

DESCRIPTION OF SURGICAL OR MEDICAL SERVICES RENDERED

jO— Doeter'i OfTicE
H— Patient's Horns

I H — Inpatient Hospital NH — Nursing Horn*

OH— Outpatient Hospital OL— Othsr Location*

^XSSR? *rCDA — 'ntenwtional Classification of Diseasos

••CPT — Currant Procedural Terminology (current edition)

TOTAL CHARGES P> S .
AMOUNT PAID P> S .
BALANCE GUI ► S

4. DATE SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED.

5. DATE PATIENT FIRST CONSULTED TOU FOR THIS CONDITION

6 PATIENT EVER HAD 6AME OR SIMILAR CONDITION?
YES I" NO ["J IF "YES" WHEN AND DESCRIBE!

7. PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION 7

vet Q no Q

0. PATIENT WAS PARTIALLY DISABLED.

I f . PATIENT WAS HOUSE CONFINED.

12. DOES PATIENT HAVE OTHER HEALTH COVERAGE?
TES L NO IF "YES" PLEASE IDENTIFY

IS. I DO NOT ACCEPT ASSIGNMENT.

DAIE PHYSICIAN S NAME i PRINT ) SIGNATURE DEGREE TELEPHONE

STREET ADDRESS CITT OS TOWN STATE OR PROVINCE

MEMORANDUM REGARDING DISPOSITION OF THIS FORM ON REVERSE SIDE Approved by Council on Medial Service. .'.MA 10-67

Fig. 3. The all -purpose CoTnb-1 health insurance claim form.

64

A SURVEY FOR THE PRACTICING PHYSICIAN

Dr. Tyson and Dr. Pressman made were
excellent ones, and I can sympathize with
them. Now, as far as the workmen's
compensation forms are concerned, that is
a question of state regulation where the
insurance industry actually doesn't have
any control.

As I have said, we will continue to look
into this question and make this irritant
a little less all the time.

A Look at

(Dr. Simmons) The final speaker is Dr.
Arthur E. Brown. Dr. Brown was born
on February 25, 1918, in Harrisburg,
Pennsylvania. He received his A.B. degree
at Harvard and his M.D. at Temple Uni-
versity School of Medicine in 1943. Fol-
lowing an internship at Philadelphia Gen-
eral Hospital, he served in the Medical
Corps of the U. S. Army from 1944 to
1946, leaving the army as a major. His
tour of duty included service as Chief of
X-ray Service for a number of general hos-
pitals serving Iwo Jima, Saipan, Tinean
and Guam.

Dr. Brown practiced internal medicine
in Harrisburg from 1949 to 1956 when he
joined the Medical Department of The
New England Mutual Life Insurance
Company as Assistant Medical Director.
He has successively been Associate Medical
Director, Medical Director and, since
1968, Vice President and Medical Direc-
tor.

In addition to his duties at The New
England Life, he has continued activity
in clinical medicine and is Clinical As-
sociate in Medicine at the Massachusetts
General Hospital in Boston.

Dr. Brown is a Diplomate of the Ameri-
can Board of Internal Medicine and a
Fellow of the American College of Physi-
cians, the American College of Chest
Physicians and the American College of
Cardiology. He is a Senior Member of the
American Federation for Clinical Research
and a member of the American Society of

(Dr. Simmons) Thank you very much,
gentlemen, for this information and dis-
cussion of these problems. It is obvious
that we don't have all of them solved at
this point, but there have been some sug-
gestions made this morning that are ap-
propriate and which will help point us in
the right direction. Things are getting
done and we are making definite progress.

Automation

Internal Medicine and the Board of Life
Insurance Medicine. He is a member of
the Massachusetts State Health Committee
and the Medical Relations Subcommittee
of the Health Insurance Council. Among
numerous other affiliations and honors, he
is Secretary of the Association of Life
Insurance Medical Directors of America
and a member of the Executive Committee
of the Medical Information Bureau where
he serves also as a member of the Sub-
committee on Health Insurance and Elec-
tronic Conversion.

He has been spending a great deal of
time during the past year studying auto-
mation and is eminently qualified to give
us this morning "A Look at Automation."

(Dr. Brown) Let me mention those sub-
jects which will not be discussed today.
Certainly I have no intention of discuss-
ing the fundamentals of computer science
although I would quickly add that such a
course as the one given by the American
College of Physicians at Madison, Wiscon-
sin, on "Computers in Medicine" was an
excellent one and probably only the first
of many similar courses yet to come. In
spite of the fact that there would appear
to be a definite relation to mortality,
today we will not discuss the purely clini-
cal use of computers in the practice of
medicine, for example, the computer in the
clinical laboratories, patient monitoring,
the control of multiple physiological func-
tions by the computer, hospital adminis-
tration, doctors' order activity in a hospi-

LIFE AND HEALTH INSURANCE TODA'Y

65

tal, computers in medical education, or
jj computers in clinical research. In all of
these fields, the computer has already
proved its worth. Much needs to be done,
particularly in relation to the software
and the expense, but this is no longer
simply a dream of the "blue sky" area.

If one goes to the National Library of
Medicine in Bethesda to research through
MEDLARS the subject of "computers in
medicine," one finds 327 articles cited
from mid-1964 to December 1967. This
gives you some indication of the increas-
ing activity in this field.

However, since the over-all subject to-
day is a survey for the practicing physician
of what really is taking place in life and
health insurance at the present time,
perhaps it's best to start by telling you a
little more of our Association of Life In-
surance Medical Directors, at least the
part of it that is germane to this discussion.

We have a number of committees. One
of these is a committee that has changed
with the times. It formerly had to do with
underwriting procedures, then laboratory
procedures, and then electrocardiographic
criteria and problems. In 1968, Dr. John
Pearson, the Chairman, divided what is
now the Medical Management and Pro-
cedures Committee into three subcommit-
tees dealing with 1., the use of para-medi-
cal personnel, 2., the use of EDP equipment,
and 3., the possibility of industry-wide
examiner panels.

The first two of these we might discuss
today, and if we have time a few other
subjects will be considered.

Dr. Simmons, I believe, was particularly
anxious that I discuss the insurance ex-
, amination situation as it now exists. As
you well know, the average practicing
physician is so very busy with his own
practice that little time is available in his
schedule for examining applicants for in-
surance, let alone for the considerable
paper work that needs to be done. Cer-
tainly, in the past decade because of this

time element, there has been an increas-
ing interest in medical economics and in
the management consultant who will ad-
vise you as to how best to spend your time
in the over-all effort of giving the best
possible patient care and at the same time
doing it efficiently enough to provide a
proper income.

Care of one's patients means care dur-
ing health, and this includes preventive
medicine; in reality, this in turn should
embrace the field of insurance medicine,
wherein your patient applies for life in-
surance when there is a real need.

Again our problem is your problem:
time. Without going into all the reasons
for the many troubles, the facts are that
in a good percentage of cases there is dif-
ficulty in obtaining an examination. The
reactions to this situation are many, and
all are an attempt to solve or partially
solve this problem.

Non-medical limits have been increased,
possibly now as much as can be done, at
least in today's economy. Among other re-
actions can be listed the groups of phy-
sicians formed in various ways and cover-
ing geographically various areas. Such a
group may be run by a physician or lay
people, but in either case the idea is an
availability factor, that is, prompt re-
sponse to one phone call and a resulting
examination by a physician known to and
approved by the medical department of
the insurance company.

There is, for example, one such or-
ganization in Chicago actually started by
two insurance brokers. My last count was
to the effect that this particular organiza-
tion had fourteen different office sites and
these people are opening offices in six
additional cities. Office hours are by and
large from 6 p.m. to 10 p.m. on weekdays
and 10 a.m. to 4 p.m. on Saturdays. This
particular service guarantees from one
phone call an examination by a doctor,
and they advertise "immediate service."

On the West Coast there are several

66

A SURVEY FOR THE PRACTICING PHYSICIAN

groups of physicians created and directed
by physicians. One such group consists of
33 physicians and another of 10. In one
group the medical department of the in-
surance company has the privilege initially
of determining which doctors it will ac-
cept and those whom it won't.

I have always thought that, instead of
being run by a doctor whom we do not
know or even by insurance brokers as is
the case in at least one instance, this type
of operation could be set up in cooperation
with a county or state medical society, the
housing and other expenses including com-
pensation probably being financed by in-
surance companies. Possibly this could be
combined with a second operation, that
of obtaining Attending Physician's State-
ments — the entire operation under the
immediate direction of a physician who
is known and respected in the area by his
colleagues. Incidentally, I know of one
such small operation working through a
county medical society in Georgia.

Then there are the so-called para-medi-
cal examinations, and this would appear
to be the important area in the immediate
future. Some of these operations are run
by physicians, some by lay individuals and
some by investigating companies. In the
majority of cases the principle is to do
away with the examination in certain
age groups and amounts and obtain a
history self-administered or taken by a
trained assistant. There would also be ob-
tained certain physical findings such as
height and weight, blood pressure and
pulse all possibly electronically recorded;
perhaps also other measurements as a
timed vital capacity, electrocardiogram
with two, six or twelve leads, a phono-
cardiogram, blood chemistries using a
multi-channel autoanalyzer, urinalysis,
chest x-ray or any combination of these.
The options would be determined by the
age of the applicant and the amount of
insurance applied for.

One such organization originating in

Kansas City now has eight offices in five
different states. This particular organiza-
tion offers service on an appointment basis
from 10 a.m. to 7 p.m. during the week
and 8 a.m. to 5 p.m. on Saturdays. They
offer 1., completion of their history foim,
2., height, weight, chest and waist meas-
urements, blood pressure and notation of
any obvious abnormalities, 3., urine for
glucose, albumin and occult blood, 4.,
phonocardiogram of the apical and aortic
areas, 5., 12-lead electrocardiogram, 6.,
SMA-12 chemistry screen and a hemo-
globin, 7., timed vital capacity and 8.,
temperature — all, believe it or not, for
$10.00.

This type of thing is becoming big
business. Speaking for myself only, I am
somewhat disturbed by this mass-produc-
tion in which we have little control. I am
disturbed by the formation of large phy-
sician groups and our inability to control
the caliber of these men. I am also troubled
by the increased problems that are bound
to arise with the variants that one sees
in doing multiple chemistry screening
tests. It might be stated here that cer-
tainly there are no good hard facts, and
therefore no complete agreement, as to
the "yield" and particularly cost/benefit
ratio related to these large screening en-
deavors.

We have always depended heavily on the
good practicing doctor, but in all honesty
it must be admitted that in a large number
of insurance applicants he is much more
important in his report to us on his own
patient than he is on doing a routine
examination for insurance unless there
are problems. It is for this reason we are
becoming more interested in self-adminis-
tered histories and also in the "assistant
physician" training program at Duke
University and other institutions.

How then can we obtain what we feel
is necessary for us and at the same time
disturb the practicing doctor as little as
possible?

LIFE AND HEALTH INSURANCE TODAY

67

As you possibly know, the studies done
on Attending Physician's Statements show
that financially we cannot afford in most
instances to request fewer statements. How-
ever, it seems to me we can proceed along
well-controlled para-medical lines.

In addition to those we have mentioned,
I believe, it won't be long until our his-
tory-taking is indeed automated. You are
aware first of the Cornell Medical Index
and Dr. Collen's work at the Oakland
Kaiser Permanente Group. Then comes
Dr. Slack's work on a computer-based his-
tory and physical examination and also
Dr. Octo Barnett's at the Massachusetts
General Hospital and Dr. Mayne's at the
Mayo Clinic. Possibly there are about
eight groups over the country working on
this.

Although most insurance companies
have computers, and I suppose the major-
ity of the larger ones third generation
computers, we still have a way to go with
respect to terminal devices. Certainly local
agency offices will have them in the not
too distant future; a few already do. On
the other hand, doctors' offices don't, but
again with regionalization I suspect in
rural and semi-rural areas this will come.
It has been predicted that within the next
five years automated medical histories
should be available to every physician and
health care facility. Service bureaus will
provide remote computer terminal service
much as the telephone company does to-
day. And in this area it should be men-
tioned that the interface of man and ma-
chine and also the computer's ability to
respond rapidly and appropriately are
of great importance. However, since we
do business over such a wide geographic
area, this problem of terminals is one of
our difficulties.

With respect to electrocardiograms, we
can certainly transmit those which our
examiners take, but this is only a small
percentage of all the electrocardiograms
we see. The majority are loans from the

practicing physician, and as yet we have
no good optical scanning device. Indeed in
most computer processing the chief limit-
ing factor is inadequate input techniques.
Here in Philadelphia, Baird and Gar-
funkel noted that the two big problems of
input and cost loomed so large that their
program was halted.

At this point you might be interested in
what one company is doing. Since 1954 we
have been coding in great detail the elec-
trocardiograms received by us. On the same
card with this electrocardiographic code
there are also coded other factors (Figures

4 and 5).

Mortality studies can be done, and the
possibility certainly exists that some day
the electrocardiogram can be underwritten
as well as received on our computers much
the way a computer diagnosis of an elec-
trocardiogram is accomplished today but
going one step further.

I would like to say just a word more
about this ECG program, for to my knowl-
edge it is the most detailed long-term study
in existence that correlates ECG, clinical
and insurance data with the mortality of
life insurance applicants. This study
project was designed in 1954 by Dr. Rich-
ard Singer who has continued to guide it
through the tempestuous seas of machine
problems. Last year Dr. Singer spoke
before this group on "Comparative Mortal-
ity and Survival Data by Medical Impair-
ment," a study sponsored by the Associa-
tion of Life Insurance Medical Directors.
At this moment many man-hours and a
moderate amount of money are being spent
converting 30,000 ECG cards; this is one
of the many problems one faces when one
works with machines.

Nevertheless, it seems to me the in-
surance industry is in a unique position to
do long-term studies. For example, in our
Bundle Branch Block Study of ECG study
cards of exposure from 1950 to 1965, only

5 of 971 entrants could not be traced.

68

A SURVEY FOR THE PRACTICING PHYSICIAN

ECG STUDY CARD

FRONT

* 3f R =lc R 4: 1! R 4: R ^ R 4: R =UHc R 4: R ^ R 4= RJ^R 5

MEDICAL FACTORS

F2 |f J

<P-(PcO

POLICY NO. NAME ftO. ECO

p 17 it it a ii dIu M a mlr am x

6-Sz\ 7-3j|B-34lt-33|lO-3«

Cl!ir pill

2 => 2 = c 2 2 3 = 2 3 c 2 3jc 2 =

tfU

ACTION

cX3|cX=fcx=k:x=W

rx^lcx^icx^

F4

rmiOL

n m i

i

Smilr^,.jorir

MEDICAL FACTORS
JilD II >4 51 X J7 B B«4llC
11-37 ll2-36 L)-3*ll4-

2=^2:

mi

MISCELL.

^A^ =>r=A=>r= 3

M

MCI

=R^
=X=>

MO
n cm

|cB=>

NT ItU

C=>
P |

fCIt I* £

'55

E ■ •>»%Blf C If (• Klb! 11 W 77*7] 74 75j Tl 77 71

't^3j20-4«|21-4sl22-4«Jzj-4_7j2«_-4 6j2S-«sjz&-SO

RIM

CJ=>
lit t in

5-7

CLASSIFICATION
AND ACTION

tTWI coi -

E=>
Him

=>

PATTERN
DIAGNOSIS

WRITTEN
COMMENTS

COLUMNS FO-F9
VIEDICAL FACTORS

COLUMNS M1-M9
ECG CODE

Fig. 4. Electrocardiographic findings coded on a computer card.

Other companies are doing excellent stud-
ies in other areas.

Much helpful information can be
gleaned from these studies, and once the
industry stabilizes somewhat with respect
to machines and the data base becomes
more readily available there will be more
information to be obtained.

To pursue the computer just a little
further, in our business several companies
are already under way in what might be
termed "Electronic Pre-Underwriting and
Underwriting." This system will relieve
underwriting people of tedious and repeti-
tive jobs in the processing of policy appli-
cations testing them within a program and
sorting out for an underwriter those ap-
plications which are found to be outside
its rules or limits. This type of procedure
is just now in its infancy; it has a long
and bright future although the early days

in this venture will be filled with problems.
In such realms as payment of medical
examiner fees the same problems exist, but
we are farther along in solving them. This
is more of a bookkeeping function and
more easily handled by the programmer
and the computer. However, when mis-
takes are made they are, as you know,
"really good ones" and then come the
public relations problems.

And so it would appear that some day
in the not too distant future our field of
insurance medicine as it applies to life
insurance will look something like this:

An insurance agent will call on a client
whose name he probably obtains from a
machine programmed to certain markets.
The agent will then obtain certain facts
and proceed to feed these into a computer
to produce what might be referred to as
"electronic coordinated estates," a program

LIFE AND HEALTH INSURANCE TODAY

69

ECG STUDY CARD

BACK

tun

cK^X=>k:X3c:L~

MIS MI4 MIS

TADS «f MS.

^C=cC=cC=c:C2c:C=c;C^C^C^C^2^c= : |cC= , (cC=|cC
^0=1c03cO=t:03 = D=

iokhiicoii ram iiioi.uu)

cE^cE^cE^cE = cE=cE=cE=cE=c:E=c:4^cE = -E=cE=cE = = 4qc4Pc4qc4=|c4%4= , ,

^cF^E^cF^-F^crF^

ou ins 9f II'!

I -29 2-28

IIS 'i i IS :
3-27 U-26 5-25

MI8 CODE

Mir I uie

■ ■I

cF=cF=cF=i5=cF=cF=

UI9 M20 M?l U22 M25 M24

A^A^C =fc ^CA^A^cA^

CM ST UAU( til iMfOLAI (HICIU

cIP

= R =lc R =lc R =lc R =1= R 4= R 4r R =t R =|c R =|c I =lc R =|c I =fc R-

ECG 12 LEADS ,

E 'J "J t3 f " " CI Cl CJ C4 C» C« C

:0^0^0^0^0=jc0=fc03ico4r0=1c0^c:0

r iivt chuc(

I HI mem e. ts oi rl u<o joi
stwmt ait Eiefpi hum at iax

cH=cH=ch:^h=ch=£h:=^

' » ,| S~"S Till I Wit, till MI ST1ID1II ICItS, till II »,1 ITItl UIIS fun

= l = Cl3cl^P::P::i:^Pcl = Cl = C8 = ^

L

OIH(R CIS CMAICE

4=1c:4qc4= = 43

CF^F%5.%5^5^5%5%5%5%5%5.%5Sfe53b5=c53

sicmiciit st [unnti nvm
|cC^C^C^C^6^C^C3 = C = cC3 = 6^6^6^G^6^6%6%6%63|c6=b63fc65c:63

MtllfiUIT ST DCWSVIOI

111 1 fAH.UIOll !*■ LEADS t US I. VICfl '/ r l Otlfl LEADS

II HIM HflUW ■ IRira I IMS ' ' ' 1 1 uini

IIHIHO I IMS

I9-IS|I«-I4| IT-19 llS-Itt I IB-II bCO-lo] 2I- » |2Z-S |2 5-7lz4-G Izs-S [ 2&-4

COLUMNS M11-M24
ECG CODE

(Many mult
Fig. 5. ECG findings coded

which will give you in hard copy a print-
out of this client's requirements not only
for life insurance but also for capital crea-
tion and accumulation.

At this point with the help of para-
medical personnel and automated labora-
tory equipment some type of computer-
based history and physical examination
will be performed with the practicing
physician stepping in on problem cases.
All fees will be paid out from the Home
Office by the computer. And then the
policy will be electronically underwritten
and spewed out untouched by human
hands except for that small percentage
in which there are medical or nonmedical
problems that the computer is not pro-
grammed to handle.

After this policy is issued, your agent

13 COLUMNS
12-LEAD ECG CODE

iple punches)

on a computer card (back).

then, in hard copy form or on the visual
display terminal in his agency, can obtain
at a moment's notice the status of this
policy. And so now before this is all an
accomplished fact, we think about what
else the future holds, and then about such
things as the rights of the individual and
invasion of privacy.

(Dr. Simmons) Thank you very much.
You have had the difficult assignment of
being "anchor man," and I appreciate the
fine way in which you have made your
presentation.

Thank you all for coming. The meeting
is adjourned.

REFERENCES
I. Abramson, J. H., Terespolsky, L., Brook, J. G.,
and Kark, S. L.: Cornell medical index as a
health measure in epidemiological studies. A

70

A SURVEY FOR THE PRACTICING PHYSICIAN

test of the validity of a health questionnaire.
Brit. J. prev. soc. Med. 19: 103-110, 1965.

2. Association of Life Insurance Medical Direc-

tions of America, 77th Annual Meetinc,
October, 1968: Transactions LII. In press.

3. Baird, H. W. and Garfunkel, J. M.: Electronic

data processing of medical records. New Eng.
J. Med. 272: 1211-1215, 1965.

4. Barnett, G. O.: Computers in patient care. New

Eng. J. Med. 279: 1321-1327, 1968.

5. Best, W. R., Mason, C. C, Barron, S. S., and

Shepherd, H. G.: Automated twelve-channel
serum screening. I. What is normal? Med.
Clinics of North America 53: 175-187, 1969.

6. Brodman, K., Erdmann, Jr., A. J. Lorce, I.,

Wolff, H. G., and Broadbent, T. H.: The
Cornell medical index. JAMA, 530-534, June
11, 1949.

7. Collen, M. F.: Automated multiphasic screen-

ing and occupational data. Arch. Environ-
mental Health 15: 280-284, 1967.

8. Collen, M. F.: Automated multiphasic screen-

ing and periodic health examinations. Pro-
ceedings of the Medical Section of the Ameri-
can Life Convention, 55th annual meeting,
June, 1967.

9. Collen, M. F.: Computer analyses in preventive

health research. Methods of Information in
Medicine 1: 8-14, 1967.

10. Collen, M. F.: Periodic health examinations

using an automated multitest laboratory.
JAMA 195: 830-833, 1966.

11. Collen, M. F.: The multitest laboratory in

health care of the future. J. Am. Hosp. Assoc.
38, 1967.

12. Collen, M. F. and Linden, C: Screening in a

group practice prepaid medical care plan. As
applied to periodic health examinations. J.
Chron. Dis. October, 1955.

13. Collen, M. F., Rubin, L., Neyman, J., Dant-

zig, G. B., Baer, R. M., and Siecelaug, A. B.:
Automated multiphasic screening and diag-
nosis. Am. J. Pub. Health 54: 741-750, 1964.

14. Computers in Medicine: Presented by the

American College of Physicians at the Uni-

versity of Wisconsin, Madison, Wisconsin.
October 7-11, 1968.

15. Encle, Jr., R. L. and Davis, B. J.: Medical Diag-

nosis: Present, past and future. I. Present con-
cepts of the meaning and limitations of medi-
cal diagnosis. Arch, of Int. Med. 112: 512-519,
1963.

16. Encle, Jr., R. L.: Medical diagnosis: Present,

past and future. II. Philosophical foundations
and historical development of our concepts of
health, disease, and diagnosis. Arch. Int. Med.
112: 520-529, 1963.

17. Encle, Jr., R. L.: Medical diagnosis; Present,

past and future. III. Diagnosis in the future,
including a critique on the use of electronic
computers as diagnostic aids to the physician.
Arch. Int. Med. 112: 530-543, 1963.

18. Symposium: Computers in Medicine. J. Chron.

Dis. 19: April 1966.

19. Mayne, J. G., Weksel, W. and Sholtz, P. N.:

Toward automating the medical history. Mayo
Clinic Proceedings 43: 1-25, 1968.

20. Northwestern Mutual Life Insurance Com-

pany: Electronic pre-underwriting: Coming
our way soon. Pillar 28: 4-7, 1968.

21. Singer, R. B.: An analysis of electrocardiographic

abnormalities in insurance applicants: Bundle
branch block and related defect. Am. Life
Convention, 50th Annual Meeting, June, 1962.

22. Singer, R. B.: Mortality in 966 life insurance

applicants with bundle branch block or wide
QRS. The Association of Life Insurance Medi-
cal Directors, 77th Annual Meeting, October,
1968. Transactions LII. In press.

23. Singer, R. B.: The usefulness of mortality and

survival data in existing medical literature.
Transactions and Studies of The College of
Physicians of Philadelphia 36: No. 3; 147-
157, Jan. 1969.

24. Slack, W. V., Hicks, G. P., Reed, C. E. and Van

Cura, L. J.: A computer-based medical history
system. New Eng. J. Med. 274: 194-198, 1966.

25. Slack, W. V., Peckham, B. M., Van Cura, L. J.

and Carr, W. F.: A computer-based physical
examination system. JAMA 200: 136-140, 1967.

Metabolic Bone Disease — Facts and Fancy 1

By ERNEST E.

IT is impossible to talk very long about
metabolic bone disease without dis-
cussing its most common and most
important component, osteoporosis. It is
equally patent that any discussion of osteo-
porosis must concern itself with its three
etiologic types: osteomalacia, osteolysis and
osteopenia. It would be well at the outset
to define these somewhat confusing terms.

We have all heard the radiologist use
the term osteoporosis to designate a lo-
calized area of decreased radiodensity.
Such usage is confusing, particularly since
the physiologist and the pathologist fre-
quently use it to infer a subnormal rate of
osteoid formation. The term osteoporosis
should be used as the internist uses it, to
designate a specific, systemic symptom com-
plex, the commonest to affect the human
skeleton, one which usually occurs after
fifty and which is much more common in
women. It often manifests itself at the out-
set by back pain, and loss of vertebral
substance results in a characteristic radio-
gram. In more extreme cases, severe
kyphosis may develop. Osteoporosis is the
underlying cause of most fractures of the
hip in the senile, and I venture to say af-
ter arthritis it is the most important dis-
abling disease in our senior citizenry.

The term osteomalacia should be used
to designate that form of generalized skele-
tal disease which results from a subnormal
availability of calcium or of phosphorous
to provide the salt necessary to mineralize
the organic matrix of bone, osteoid. In the
mature skeleton, it is properly called
osteomalacia. In the growing skeleton, it is

Thomas Dent Mutter Lecture LXXX, The Col-
lege of Physicians of Philadelphia, 8 January 1969.

- Professor of Pathology, Temple University
School of Medicine, Philadelphia, Pennsylvania
19140.

lEGERTER, m.d. 2

called rickets. If this salt deficiency in
rickets is due to an inability of the kidneys
to conserve calcium or to conserve phos-
phorous, it is called renal rickets. When
renal rickets is caused by a specific calcium
ion loss, and this occurs most often when
both the glomeruli and the tubules are
affected because of a congenital nephro-
anomaly such as polycystic kidneys, less
often to an acquired glomerulonephritis,
the proper term is renal osteodystrophy.
When the renal rickets is due to a con-
genital inability to conserve phosphorous
by the renal tubules, the term hypophos-
phatemic rickets is now used. In the recent
past, this was known as Vitamin D re-
fractory rickets, and before that the
Fanconi syndrome. Thus the term renal
rickets may mean either the calcium defi-
cient renal osteodystrophy or the phos-
phate deficient hypophosphatemic rickets.

Incipient or latent osteomalacia is usu-
ally called Milkman's syndrome. When
Milkman published his definitive paper in
1934 (1), he thought that he was describ-
ing a new clinico-pathologic entity. Later,
Fuller Albright (2) recognized this case as
one of mild and latent osteomalacia. In
Milkman's syndrome there are one or more
painful fractures, or, better, pseudofrac-
tures, without trauma or malalignment.
Most cases of osteomalacia are the result
of an occult hypophosphatemic rickets un-
diagnosed throughout childhood.

The term osteolysis should be used to
designate the abnormalities of deossifica-
tion brought about by an excessive rate in
absorption of bone. For nearly a half cen-
tury we believed that it was always pro-
duced by hyperparathyroidism. Now we
know that a rare, and therefore unim-
portant, cause is hypervitaminosis D. Later
I shall mention the possibility of a third

7 2

E. E. AEGERTER

mechanism of osteolysis, a mechanism that
is still unproven.

Finally, I like to use the term osteopenia
to designate a reduction in bone mass be-
cause of an inability to elaborate sufficient
osteoid to support skeletal growth in
youth or to balance physiologic erosion in
maturity (3, 4). Its purest form is seen in
the congenital skeletal dysplasia, osteo-
genesis imperfecta. Scurvy is a good ex-
ample of a dietary deficiency type of
osteopenia. Osteopenia in the adult skele-
ton is a more obscure expression of a nega-
tive osteoid balance, often of unknown
etiology.

Now we have defined osteoporosis as a
clinical symptom complex. Osteomalacia is
a pathologic entity caused by an inability
to adequately mineralize osteoid; osteoly-
sis is a pathologic entity, a negative
osteoid balance due to excessive bone re-
sorption, and osteopenia a negative osteoid
balance caused by an inhibition of osteoid
formation. Now let us turn our attention
to a review of the pertinent features,
some fact and some fancy, concerning the
pathogenesis of these three important
types of metabolic bone disease.

In regard to osteomalacia, the facts in
most instances are more evident than the
fancy. Most cases of simple childhood
rickets in this country are caused by a
dietary deficiency in vitamin D with in-
adequate absorption of calcium through
the gut wall. The classical radiograph of
rickets reveals widening, cupping, spread-
ing, and spurring in the metaphyseal area.
These changes are due to the replacement
of normal rigid bone with irregular masses
of osteoid and chondroid which are inter-
mixed without adequate mineralization.
Failure of calcium absorption due to in-
testinal diseases, such as steatorrhea, fibro-
cystic disease of the pancreas, or congenital
bile duct atresia, is much less common
though no less real. Rickets, or osteomala-
cia, depending upon the age of young
women who place an extraordinary de-

mand on their calcium stores by multiple
rapidly repeated pregnancies and pro-
longed lactation probably occurs, but in
our experience only in cases in which
dietary calcium is in jeopardy.

Renal osteodystrophy has now been ade-
quately recorded and amply corroborated
in the recent literature (Fig. 1). In this
disease, the kidney in chronic uremics
wastes calcium. The reason for this prof-
ligate spending of the precious calcium
ion is not completely understood, but we
presume it to be an abnormal utilization
of all available basic cations including
those of calcium in an attempt to neu-
tralize the acidosis of a chronic uremia
which is sufficient to inhibit ammonia
synthesis but not severe enough to kill the
patient for a number of years (2). A con-
tinuous withdrawal of calcium ions from
the blood stimulates the parathyroids and
eventually causes secondary hyperpara-
thyroidism (Fig. 2). The radiogram does
not differentiate the various types of
rickets, nor can the microscopist, since the
sections reveal the same histopathologic
alterations in renal osteodystrophy as
those found in ordinary rickets.

Hypophosphatemic rickets (Fig. 3) is in
reality a group of diseases based on a
variety of congenital enzymatic defects,
probably seated in the kidney tubule lin-
ing cells. Frazer divided these conditions
into six subtypes, depending upon the re-
lated metabolic defect, but in all there is
an inability to reabsorb phosphates from
the glomerular filtrate inducing a phos-
phorous deficiency rickets. Massive doses
of vitamin D may reverse this process in
three of these types, hence the name vita-
min D refractory rickets, though the site of
action of this drug, whether gut wall or
renal tubule, is still undetermined. There
has been much speculation concerning the
nature of this functional defect. Elongated,
swan-neck of the proximal convoluted
tubules, peritubular inflammatory reaction
with fibrosis and a host of other lesions

Fic. L Renal osteodystrophy. Kidney disease results in a utilization of calcium ions needed
for mineralization of osteoid. Failure of rigidification results in dramatic skeletal distortion.

/ 1

I I VEGER I I R

I'K.. 2. The skull in advanced sccondan In pel paialin loidism. I lie "snow-sto! in" granu-
larity is the same as that found in parathyroid adenoma.

have been repotted, hut ,u present it is
widely believed that there is no consistent
si i iK i ural alteration.

1 hough il is i ,i] e. we should men! ion ,i
loin th type ol litkets in this discussion. Il
is (.died hypophosphatasia or, better, hypo-
phosphatasenha, because there is ;i dis-
appearance ol the alkaline phosphatase
from the blood and from the cells where
it is normally Eound (Fig. 1). Though phos-
phorylethanolamine is found in the urine
.nid though this substance is a substrate
for alkaline phosphatase in the test tnbe,
it probably does not enter into the
pathogenesis of the disease and ma) be
only a by-product since it is hydrolized at
a normal rate when injected into the pa-
tient with hypophosphatasemia.

A few years ago a new hormone was de-
scribed by Copp (5). It is now called thyro-
cahitonin because it appears within and

may be elaborated In the acinar cells of
the thyroid (6) rather than the parathyroid
as originally proposed. Its activity is ap-
parently concerned with the deposition of
mineral in osteoid, reducing the serum
calcium level. Its action appeals to be the
precise antithesis of parathormone which
of course mobilizes mineral from bone to
cause a rise in the serum calcium. Though
as yet there is no data to support it, it is
tempting to associate this hormone, or
rather its lack, with the pathogenesis of
hypophosphatasemia.

In Milkman's syndrome, the full-blown
fracture appears as a broad radiolucent
line which may cross the entire width of
the shaft (Fig. 5). In earlier cases the le-
sion may be just as painful though much
less obvious. In essence, these lesions rep-
resent an inability to mineralize, that is, to
rigidify, the osteoid that is produced to

Fir,, Hypophosphatemic rickets. This phosphorous deficiency type of rickets produces
pseudofractures like those of Milkman's sviulrome (see Fig. 5). Both femurs arc involved in this
patient.

replace the bone lost In physiologic ero-
sion. Naturally il is seen best at points oi
stress where bone turnover is most active.
In more advanced cases, hank fracture
occurs and eventualh this lack ol litiidifi-
cation ma\ produce skeletal damage of
grotesque proportion.

The pathogenesis of osteolysis is not as
clear as that ol most cases of osteomalacia.
Bui \ve know that parathormone increases
the number of osteoclasts and that bone
resorption is accomplished through their
action (7, 8). We are handicapped in this
area because as yet we have no practical

76

E. E. AEGERTER

I k.. 1. Hypophosphatemia. In lliis disease,
mineral sail is available hut I here is failure of
deposition in osteoid. This phenomenon suggests
l lit- possibility of failure of thyrocalcitonin activity.

means of measuring the serum parathor-
mone level. We do know, however, thai
parathormone has at least two sites of ac-
tion. It acts directly upon bone to cause
deossification mediated by osteoclastic ac-
tivity. But it also acts upon the kidneys to
inhibit phosphate reabsorption from the
glomerular filtrate and thus causes a phos-
phorous diuresis. Hyperparathyroidism is
characterized by a high serum calcium
level and the diagnosis should rarely if ever
be made in its absence. Diagnosis can fre-
quently be made by examination of the X-
ray. The "snow-storm" skull is one of the
few pathognomonic findings in all radiog-

raphy. The lacy cortices of the phalanges
are less trustworthy and the loss of the
lamina dura is to be regarded as only help-
ful .11 I JCSt.

In severe and prolonged hyperparathvj

Fie. 5. Milkman's syndrome. Wide radiolucent
bands appear at stress points. These are pseudo-
fractures, loss of rigid bone and replacement by
unmineralized osteoid. Since the latter is flexible
though tough, bending occurs without malalign-
ment.

METABOLIC BONE DISEASE

77

roidism, the skeleton is weakened at stress
points to cause dramatic distortion. The
cortex virtually disappears and the marrow
is replaced by a fibrosing process, hence,
the name osteitis fibrosa. Simultaneous
osteoblastic and osteoclastic activity of this
degree are seen in no other diffuse skeletal
disease with the possible exception of
Paget's.

Circumscribed areas of massive bone
destruction, brown tumors, occur in very
late hyperparathyroidism. It is my belief,
a belief shared as far as I know, by no
one of my acquaintance, that these so-
called brown tumors are caused by intra-
osseous hemorrhage due to a structural
weakening because of osteoclastic activity
and multiple infractions. The presence of
numerous giant cells, which I believe to
be osteoclasts, in these so-called tumors
causes these lesions to be frequently mis-
diagnosed giant cell tumors of bone (9, 10).

Nephrocalcinosis occurs because of the
high calcium and phosphorous ion levels
in the fluids which perfuse the kidney.
About five percent of all renal stones are
said to be caused by this condition.

Clear cell hyperplasia, or as it is now
more commonly called, primary parathy-
roid hyperplasia, was described by Mal-
lory and Castleman in 1935 (11). Though
a description of this condition is carried in
every textbook of pathology and in most of
internal medicine, it probably does not
exist as a clinico-pathologic entity. Since
parathyroid adenoma itself is in no sense
a neoplasm, but like nodular hyperplasia
of the thyroid, an endocrine dysplasia,
primary or clear cell hyperplasia is prob-
ably nothing more than a more diffuse
manifestation of what we have always
called parathyroid adenoma. Primary para-
thyroid hyperplasia cannot be differen-
tiated from parathyroid adenoma by the
clinician and the distinction should not
be made by the pathologist (12).

The problems of hyperparathyroidism
have recently been compounded by the

recent introduction of some experimental
data suggesting a second mechanism of
bone lysis. Reidcnbcrg (13), at Temple,
produced a negative calcium balance in fat
women on an acaloric diet. He assumed
this was due to the acidosis which always
occurs under these conditions. He pro-
duced the same effect in a patient who was
hypoparathyroid, suggesting that the neg-
ative balance was independent of the
parathyroid glands. The same results had
been obtained previously by Lehman and
co-workers in two hypoparathyroid pa-
tients. Since the urine calcium was greater
in amount than could be accounted for on
the basis of serum loss, it is assumed that
it came from the skeleton stores by the
direct action of the acidotic state on bone.
Thus, after almost exactiy a century of ex-
perimentation, hypothesis and argument,
we may be proving the validity of von
Recklinghausen's original explanation for
the bone destruction in some of his cases
of osteitis fibrosa cystica.

Finally, the pathogenesis of most cases of
osteopenia is largely conjectural. We can
only assume that in osteogenesis imperfecta
there is a congenital enzymatic defect
with failure of maturation of the osteo-
blasts, resulting in an inability to produce
sufficient osteoid to meet the exigencies of
stress. The precious little bone that is
formed is of woefully shoddy quality.

To synthesize an adequate amount of nor-
mal osteoid, the osteoblast must be pro-
vided with sufficient amounts of necessary
building blocks, amino acids and vitamin
C. It must be subjected to a certain level
of stress and it can function only in the
climate of adequate estrogen and androgen
influence.

Scurvy is a type of osteopenia. In some
manner as yet undetermined, ascorbic
acid is required for the synthesis of the
three polypeptide chains which are the
components of the collagen fibers of con-
nective tissue and osteoid. Because the
calcium-phosphorous ion product is nor-

78

E. E. AEGERTER

mal in this disease, the osteoid that is
formed is mineralized, and so by contrast
it stands out abnormally prominent in
the radiogram, giving us the white line of
provisional calcification and the character-
istic ringed epiphyses. The radiolucent
scorbutic zone appears because of the sub-
normal osteoid production and consequent
lack of opaque mineral. Occasionally one
will encounter dietary eccentrics who re-
fuse to eat protein. These people may de-
velop osteopenia and it is presumed that
they fail to supply their osteoblasts with
the required amino acids.

We have had the opportunity of study-
ing a very severe case of osteopenia. Poor
in fortune, but rich in pride, this luckless
soul attempted to exist on a handful of
crackers and a cup of tea daily for months.
Eventually her skeleton, ravaged by the re-
lentless progression of physiologic erosion
without the capacity to replace lost bone,
simply wore out.

More often those who suffer from the
malabsorption syndrome or those with se-
vere and prolonged diarrhea may be de-
prived of these necessary constituents for
bone production.

We need only mention the importance
of stress in skeletal maintenance. When a
fractured limb is immobilized in plaster,
an X-ray demonstrable disuse atrophy oc-
curs in from six to eight weeks.

The importance of adequate steroid hor-
mone influence is dramatically illustrated
in the patient who has ovarian hypogene-
sis. Unfortunate women who must undergo
surgical castration before the menopause
suffer a similar depletion of their skeletons.
The cortices are thin; the cancellous bone
is almost non-existent.

We have now examined the pathogene-
sis of osteomalacia, inadequate bone rigidi-
fication; of osteolysis, abnormal bone de-
struction; and osteopenia, inadequate bone
restoration. Now let us consider the
pathogenesis of the clinical symptom com-
plex, osteoporosis.

All human skeletons, regardless of race,
begin to lose bone mass soon after the age
of 40 and there is a relentless progression
of this loss for the remainder of life at the
average rate of 3 percent per decade in
males and 8 percent per decade in females.
The cause for this reduction in bone mass
is obscure. Frost (14) and Jowsey (15), in-
dependently and using different tech-
niques, concluded that this loss is due to a
speeding up in the rate of bone resorption
in the latter half of life. This has been
challenged by Hegsted (16) and others and
I find their conclusions untenable when
applied to all cases on the basis of their
published data.

Nordin (17) in England, and Lutwak
in this country, have been the most ardent
champions of the thesis that a low calcium
diet is an important cause of osteoporosis.
This quick and easy explanation has been
adopted by many others (18, 19, 20,
21, 22), who, however, have failed to pro-
vide satisfactory evidence of its truth. Garn
and associates (23) and Smith (24), using
the more objective methods of measuring
metacarpal cortical thickness and relative
vertebral density in very large groups of
varying ethnic and geographic distribu-
tion, have concluded that there is no rela-
tion between bone loss and calcium intake.
It is now possible to state unequivocally
that a dietary deficiency of calcium is not
an important cause of senile osteoporosis
in this or any other country.

It can also be said with equal emphasis
that stress is a proven factor in osteoid
elaboration. Cochran and co-workers,
among others, have provided convincing
evidence that the mechanism is probably
through the action of the piezo-electric po-
tentials. Concerning the importance of hor-
mones, there is much clinical and therefore
circumstantial evidence but less factual
data, though Smith (24) found that rela-
tive vertebral density and the amount of
axillary hair are consistently statistically
related.

METABOLIC BONE DISEASE

79

Posner, and later others, have shown
that mineral is first deposited in osteoid in
an amorphous form and the apatite crystal
grows as the osteoid matures. The earlier
phase is less stable. If fluoride is made
available, it will replace a hydroxyl group
of the amorphous form, stimulating the
growth of the apatite crystal, thus convert-
ing an unstable form of osteoid to a stable
form of bone. Hegsted (16) found that rel-
atively high levels of fluoride in the water
supply significantly reduces the incidence
of osteoporosis. In many clinics through-
out the country, osteoporotics are treated
with 20 to 60 milligrams daily of sodium
fluoride over an extended period up to 2
to 3 months. About 50% of these patients
attain symptomatic relief.

In review, we may now define osteo-
porosis as a clinical symptom complex re-
lated to a progressive reduction in bone
mass caused by osteomalacia, osteolysis or
osteopenia. It is probable that a combina-
tion of two or perhaps all three of these
mechanisms is responsible in most cases.
Every effort should be made to properly
evaluate the cause or causes in each case
since fluoride therapy could hardly be ex-
pected to benefit those cases in which
osteopenia is the cause, nor hormones in
an instance of pure osteolysis. It is prob-
able that in most cases the exact patho-
genesis will remain unknown whether one
uses X-ray studies, chemical analysis or
biopsy. The biopsy is the least valuable of
the three methods, notwithstanding sev-
eral publications to the contrary. We have
tried all the reported techniques (26, 27)
and found them equally worthless. Prac-
tically speaking, in the majority of cases
one will be forced to treat them by the
standard method of high protein, high vit-
amin D and C diet, correction of hormone
and calcium imbalance, an exercise regi-
men, and a therapeutic trial with sodium
fluoride. So treated, the great majority of

cases, if not all, will eventually attain
symptomatic relief.

REFERENCES

1. Milkman, L.: Am. J. Roentgenol. 32: 622, 1934.

2. Albright, F., Burnett, C, Parson, W., Reifen-

stein, E. p and Roos, A.: Medicine 25: 399,
1946.

3. Albricht, F.: Ann. Int. Med. 27: 861, 1947.

4. Nordin, B.: Advances in Metabolic Diseases 1:

125, 1964.

5. Copp, D., and Henze, K.: Endocrinology 75: 49,

1964.

6. Hirsch, P., Voelkel, E., and Munson, P.: Sci-

ence 146: 412, 1964.

7. Johnson, W.: Arch. Path. 10: 197, 1930.

8. Trueta, J.: Scottish Med. J. 11: 33, 1966.

9. Jaffe, H., and LiCHTENSTriN, L.: Am. J. Path.

18: 205, 1942.

10. Aegerter, E.: Am. J. Path. 23: 283, 1947.

11. Castelman, B., and Mallory, T.: Am. J. Path.

11: 1, 1935.

12. Howard, J.: Transactions and Studies Coll.

Phys. Phila. 30: 55, 1962.

13. Reidenberc, M., Sevy, R., and Cucinotta, A.:

Proceed. Soc. Exp. Biol, and Med. 127: 1, 1969.

14. Frost, H.: Mathematical Elements of Lamellar

Bone Remodeling. Charles C Thomas, Spring-
field, 111., 1964.
I ">. Gershon- Cohen, J., and Jowsey, J.: Metabolism
13: 221, 1964.

16. Hegsted, D.: Federation Proceed. 26: 1747, Nov-

Dcc. 1967.

17. Nordin, B.: Proc. Nutr. Soc. 19: 129, 1960.

18. Kelly, M., Little, K., and Courts, A.: Lancet

II: 1125, 1959.

19. Scott, P., McKlsick, V., and McKusick, A.: J.

Bone and Joint Surg. 45: 125, 1963.

20. McClendon, J., Jowsey, J., Gershon-Cohen, J.,

and Foster, W.: Nutrition 77: 299, 1962.

21. Scott, P., Greaves, J., and Scott, M.: Brit. J.

Nutrition 15: 35, 1961.

22. Harrison, M., and Fraser, R.: J. Endocrinology

21: 197, 1960.

23. Garn, S., Rohmann, C, and Wagner, B.: Federa-

tion Proceed. 26: 1729, Nov.-Dec. 1967.

24. Smith, R.: Federation Proceed. 26: 1737, Nov-

Dec. 1967.

25. Cochran, G., Pawi.uk, R., and Basett, C: Clin.

Orthop. 58: 249, 1968.

26. Beck, J., and Nordin, B.: J. Path, and Bact. 80:

391, 1960.

27. WRAV, J., SUGARMAN, E., AND SCHNEIDER, A.:

J.A.M.A. 183: 118, 1963.

Memoir of Leighton Francis Appleman

1874 1968*

By WARREN S. REESE, m.d.

IT is my sad duty to record the passing
of Leighton Francis Appleman, m.d.,
at one time my chief at Wills Eye
Hospital, and one of the jolliest, best liked,
most congenial, unusual and faithful of
the Attending Surgeons. To my knowledge,
he was the only Attending Surgeon who
continued to attend and work in the clinic
regularly after attaining emeritus status.

He died in Glenside, Pa., on November
26, 1968, at the age of ninety-four, in a
house he had remodeled which was orig-
inally an old mill dating back to about
1740.

Dr. Appleman had a varied and interest-
ing career. He was born on Feburary 19,
1874, at Glenside, Pa., on the farm of his
maternal grandfather, David Heist.

He received his early education at the
Cheltenham Public School, Friends Cen-
tral High School, and Princeton Prepara-
tory School. He entered Princeton Uni-
versity in 1892, but left in his junior year
to matriculate at Jefferson Medical Col-
lege, from which he was graduated in 1897.
His internship was served at the Reading
General Hospital, and the following year
he opened his office in Philadelphia. Ob-
stetrics was his first interest, but this was
short lived, and in 1899 he became as-
sociated with Dr. Hobart A. Hare, Pro-
fessor of Therapeutics at Jefferson, and
continued in that department until 1934.
Dr. Appleman taught pharmacy at Jef-
ferson. Having been one of his pupils, I
can attest to his popularity and interest-
ing manner of teaching. Indeed, I con-

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

sidered him one of the best teachers. I am
sure that his students will remember
Basham's Mixture, Donovan's Solution and
Coxe's Hive Syrup, the latter a "vehicle"
for Dr. Appleman's favorite Spoonerism:
"Gentlemen, that is not Hive's Coxe
Syrup." During this time, he acted as
Assistant Editor of Progressive Medicine
and carried on an active practice in oph-
thalmology which he began in 1899 when
he was appointed to Dr. Howard F. Han-
sell's Staff in the Polyclinic, later Graduate
Hospital. He was also Clinical Assistant
to Dr. George E. deSchweinitz from 1899
to 1902, when the latter was Professor of
Ophthalmology at Jefferson. In 1914, he
was appointed Associate Professor of Oph-
thalmology in the University of Pennsyl-
vania Graduate School and lectured on
ocular therapeutics.

Dr. Appleman was made Attending
Surgeon at Wills Hospital in 1924, serving
until his retirement in 1939. He was also
Ophthalmologist to the Burd School,
Douglas Memorial Hospital, and Consult-
ing Ophthalmologist to Mercy Hospital.

He was a member of the Philadelphia
County Medical Society, the Pennsylvania
State Medical Society, the American Medi-
cal Association, the American Ophthalmo-
logical Society, and a Fellow of The Col-
lege of Physicians of Philadelphia and the
American Academy of Ophthalmology and
Oto-Laryngology.

He also held membership in the His-
torical Society of Pennsylvania, the Geo-
graphic Society, the Fort Washington His-
torical Society, the Sons of the Revolution,
the Genealogical Society of Pennsyl-
vania, the Episcopal Church and the Epis-
copal Church Club.

80

MEMOIR OF LEIGHTON FRANCIS APPLEMAN

81

Dr. Appleman was among the first to do
intracapsular cataract extractions rou-
tinely at Wills Hospital, and he was one
oi the few, if not the only man, who
presented an unusual case in which he

had made a mistaken diagnosis before the
august College of Physicians.

He is survived by a son, Leighton F.
His wife, Anna Hough Parson, passed
away on January 21, 1944.

Memoir of Joseph Howard Cloud
1872-1968*

By VICTOR C. VAUGHAN, III, m.d.

JOSEPH Howard Cloud, a member of
The College of Physicians of Phila-
delphia for fifty-eight years, died on
April 27, 1968, four days before his ninety-
sixth birthday.

Dr. Cloud was born in West Philadel-
phia, in an area then known as Heston-
ville, and moved with his family to Ard-
more in 1884. After attending Friends
Select School, he entered Jefferson Medi-
cal College and was graduated with the
Class of 1892. He served a year as assistant
to Dr. H. M. Neale in Upper Lehigh,
Pennsylvania, and then spent eight years
in the anthracite coal region as physician
for the miners. In 1901, he returned to
Ardmore as assistant to Drs. Robert H.
Alison and George Gerhard. Later he es-
tablished his own practice on West Mont-
gomery Avenue, where he remained active
until 1947.

Dr. Cloud joined the staff of the Bryn
Mawr Hospital in 1906 and became a
member of The College of Physicians of
Philadelphia in 1910. He served in France
with Base Hospital #10 of the Pennsyl-
vania Hospital from 1917 to 1919, holding
the rank of major. He was a member of the
Montgomery County Medical Society and
of the American Medical Association. His
addresses and medical publications include
a report of a case of chronic tetanus fol-
lowed by scarlet fever (1893), a report on
the mining town and its company doctor
(date uncertain), discussion of the Rela-
tion of the Physician to Beneficial Soci-
eties (1901), a Brief Review of 500 Cases

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

of Labor (1902), an address to the graduat-
ing class of the School of Nursing of Bryn
Mawr Hospital (1911), a paper on Con-
valescence, with Special Reference to the
Philadelphia Area (1937), and a report on
Medicine in the Horse and Buggy Days
(Philadelphia Medicine, November 13,
1959). Dr. Cloud regularly made his medi-
cal rounds on horseback in mining country
and with horse and buggy in the early
years of his practice in Ardmore.

Dr. Cloud was a fifth generation de-
scendant of Jeremiah Cloud (who came to
America with William Penn in 1682) in a
line which included at least two other
physicians. His grandfather, Joseph Cloud,
was a Revolutionary War soldier. He him-
self was a birthright member of the Re-
ligious Society of Friends.

In 1914, Dr. Cloud married Elisabeth
Valentine Perot. Besides Mrs. Cloud, sur-
vivors include Mrs. Victor C. Vaughan,
III, of Germantown, Laurence P. Cloud,
m.d., of Boston, Massachusetts, and three
grandchildren.

Dr. Cloud's inquiring quality was a
hallmark of a career which spanned the
history of modern medicine. (He was thir-
teen years old when Louis Pasteur im-
munized Joseph Meister against rabies.)
His eagerness and enthusiasm for new in-
formation and ideas in medicine and other
sciences kept him in attendance at medical
gatherings and visiting the observatory at
Bryn Mawr College well after his retire-
ment. He will be remembered as a gentle
and devoted physician and friend, with
aspects of thoughtfulness, simplicity and
serenity that gave rich meaning to his
Quaker ancestry.

82

Memoir of John Arthur Daugherty
1902-1968*

By EDWARD C. RAFFENSPERGER, m.d.

JOHN Arthur Daugherty, m.d., was
born August 12, 1902, at Carlisle,
Pennsylvania. His early education
was in Harrisburg. He was graduated from
the University of Pennsylvania in 1924 and
from Jefferson Medical College in 1928.
After internship and residency training at
the Harrisburg Hospital, he remained
there as an attending physician until his
sudden death at his home on August 28,
1968.

Besides being Chief of Staff of the Har-
risburg Hospital just prior to his death,
he was also a member of many state and
national professional organizations, includ-
ing the American Diabetic Association,
American Heart Association, and the
American College of Physicians. He was a
delegate to the Pennsylvania Medical So-
ciety. He became a member of The College
of Physicians of Philadelphia in 1955.

He became a corporate member of the
Medical Service Association of Pennsyl-

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

vania (Blue Shield) in 1944, elected Presi-
dent in 1915, and became Chairman of
the Board in 1966. During this time he
served one term as President of the Na-
tional Association of Blue Shield Plans.
At the time of his death he was a Director
and Chairman of the By-Laws Committee.

His greatest service to organized medi-
cine has been in the area of prepay medi-
cal care. He was largely responsible for the
steady growth of the Blue Shield Plans,
both state and national. It was through
his efforts that Blue Shield grew from a
"paper" organization to the largest Blue
Shield plan in the United States, serving
all of Pennsylvania.

He was a tireless worker and a good
physician. He will be missed by his many
patients and friends as well as by his as-
sociates at Blue Shield.

Dr. Daugherty is survived by his wife
and three sons, Richard M., Ronald M.
and the Reverend Robert M., and also by
a sister, Mrs. Clarence E. Ulrich, and a
brother, J. Dwight Daugherty, ph.d., of
Kutztown, Pennsylvania.

83

Memoir of Matthew S. Ersner
1890-1968*

By DAVID MYERS, m.d.

IT is an honor indeed to write about my
chief, "Matt" Ersner. I first met him
while a student in the School of Medi-
cine of Temple University. This was in my
junior year, 1929. Dr. Ersner had just been
appointed Professor of Otology in his
alma mater. We were introduced to the
subject of otology, and I was associated
with him from then until his death.

Matthew S. Ersner came to this country
as a child, his family having immigrated
from Russia. He worked very hard from
early childhood. He often told me of his
days as a Western Union messenger boy,
as well as his many other jobs.

He had a fine tenor voice and supple-
mented his income while at school by sing-
ing in a choir, in the local churches and
synagogues.

In 1912, he was graduated from the
Temple University School of Medicine.
He then did post-graduate studies in bac-
teriology and immunology with the late
Dr. John Kolmer. Through his association,
he began to do studies in middle ear and
mastoid infections with the late Dr. George
M. Coates. This led him into the study
of otology.

The early days in our field in the pre-
antibiotic era were days of horrendous
complications and heroic surgery because
of the serious complications that resulted
from mastoid and sinus infections. "Matt"
Ersner was superb in his attack on these
problems. He was bold and thorough. He
accepted the most serious and urgent prob-
lems without hesitation, and his technique
was magnificent. In the days before the

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

introduction of the high speed electric
drills and cutting burrs and the binaural
operations microscope, a mastoidectomy
was a real challenge. The operation was
done with mallet, chisel and gouges.
Watching "Matt" at work was like watch-
ing a fine sculptor; he was the "Michel-
angelo of Otology." Later he helped pio-
neer new techniques, such as the Lempert
fenestration operation, and he encouraged
work in new fields, such as the field of
rhinoplasty and the field of endaural,
per-meatal otologic surgery, following the
development of Samuel Rosen.

He did a great amount of research work
and pioneered many new procedures. His
list of publications was tremendous and
covered a wide variety of subjects. His
writing and study were done late at night,
on weekends and holidays. This often was
added on to an already tumultuous day
which started early and ended late. A
typical day would be marked by an early
start, a long morning in the office, a quick
lunch, an afternoon of surgery, rounds,
lectures and teaching. When the day's
work in the hospital was completed, nu-
merous house consultations were made
(again in pre-antibiotic style), to be fol-
lowed by a late supper, if he was lucky,
and then by emergency operations until
late in the night and early morning.

He was a wonderful teacher who spent
a great amount of time in instructing his
students in all the things he knew. He was
very generous in allowing young men to
get started in surgery, and he would stand
by the operating table patiently while we
made our first awkward starts. He was an
exciting lecturer and professor. He gave a
great deal of himself to students and resi-

84

MEMOIR OI MATIIII.W s I.RSM.R

85

dents at the Temple University Medical
Center. He was very active in alumni af-
fairs and helped build up the Temple
University School of Medicine in its ear-
liest days. He was very attached to his
alma mater and gave generously of him-
self. His interests in communal activities
were numerous. He was very charitable,
served on many committees and was an
all-around member of the Philadelphia
community.

Over the years, he kept close contact
with all of his ex-residents and friends.
Many of the young men that he trained
later became professors in medical schools
throughout the country. Other men are
chiefs of service at many hospitals through-
out the United States. It would be im-
possible to name the great number of men
who came under his influence. For many
years he was Professor and Lecturer at the
Graduate School of Medicine of the Uni-

versity of Pennsylvania, and year after
year he never missed his weekly lectures,
which he prepared each time as though
he had never given them before.

He was a wonderful son, father, husband
and brother. His family contacts were very
close and intimate. The Ersner family
gathered about their big brother.

I might dwell upon his great suffering,
when he became ill and required an am-
putation of his leg, and his fight for re-
covery and rehabilitation. Even then he
carried out his office work and care of
his patients, although he had great dif-
ficulty getting around on an artificial
limb.

I could go on and on about the merits
of this wonderful man, who made a place
for himself in American medicine after
having arrived in this country as a poor
immigrant boy, who worked his way up to
the highest rank in our profession.

May he rest in peace.

Memoir of Archer P. Crosley, Jr.
1920-1968*

By JOHN KAPP CLARK, m.d.

A RCHER P. Crosley, Jr., m.d., was born
/-\ in Trenton, New Jersey, on October
^30, 1920. In 1942, he was graduated
from Ursinus College cum laude with de-
partmental honors in biology. In 1945, he
was graduated from the University of
Pennsylvania School of Medicine, where
he was a member of Alpha Omega Alpha,
and served an internship at the Hospital
of the University of Pennsylvania. Follow-
ing military service in World War II
when he attained the rank of Captain, he
returned to the Hospital of the University
of Pennsylvania for a residency in Internal
Medicine and later joined the Staff of the
Renal Section of the Department of Medi-
cine. After a brief tour in the pharma-
ceutical industry, Dr. Crosley went to the
University of Wisconsin where he estab-
lished a unit for the study of the physiol-
ogy and pharmacology of the human kid-
ney in health and disease. At Wisconsin,
Dr. Crosley was successful in developing
the nitrous oxide blood flow method for
measurements of the hemodynamics of the
human kidney in the anuric state. He also
demonstrated in the normal kidney actual
values for renal weight in grams by divid-
ing absolute blood flow values obtained
by PAH clearances by values obtained by
nitrous oxide which, of course, gives blood
flow in terms of volume per unit weight.

In addition to his independent work,
he collaborated with many other groups
in measuring renal function in a variety of
clinical situations. In the course of his

* Published at the request of the Council of The
Council of The College of Physicians of Phila-
delphia. This memoir also appeared in The Phar-
macologist, Vol. 11, No. 1, Spring 1969, and is re-
published with permission.

interest in the kidney, Dr. Crosley came
to use known drugs as tools to investigate
physiologic phenomena, in addition to his
interest in the properties of new thera-
peutic agents, and as a result of his drug
studies, was elected a member of the Amer-
ican Society for Pharmacology and Ex-
perimental Therapeutics in 1958. While at
Wisconsin, Dr. Crosley was also active in
general affairs of the medical school. He
was a member of the Executive Committee
and Chairman of the Committee on Post-
graduate Medical Education, as well as
serving as Senior Attending Physician. He
was certified by the American Board of In-
ternal Medicine in 1955.

In 1958, Dr. Crosley's interests in clinical
pharmacology brought him back to Phila-
delphia, where he joined the Research and
Development Division of Smith Kline and
French Laboratories. At the time of his
death, he was directing the clinical research
at Smith Kline and French's clinical
pharmacology units at Presbyterian-Uni-
versity of Pennsylvania Medical Center
and the Pennsylvania Hospital. He was
also Acting Director of Research at the
Research Institute of the Presbyterian-
University of Pennsylvania Medical Cen-
ter, as well as Chief of the Renal and
Electrolyte Section and Director of Clinical
Investigation. He was Assistant Professor
of Medicine in the School of Medicine of
the University of Pennsylvania, a consult-
ant in renal disease to Mercy-Douglass
Hospital, and medical consultant at Inglis
House.

Dr. Crosley was nationally recognized as
a leader in clinical pharmacology. He
served as a consultant and member of

86

MEMOIR OF ARCHER P. CROSLEY, JR.

87

special investigative committees for the
Food and Drug Administration and the
Commission on Drug Safety. He was a
member of the ASPET Commitee on
Toxic Reaction to Drugs from 1964 to
1965 and was, at his death, a member of
the Executive Committee of the Division
of Clinical Pharmacology and its Educa-
tional and Professional Affairs Subcom-
mittee. In addition to the Pharmacology
Society, Dr. Crosley belonged to many
other medical and scientific groups. He
was a Fellow of the American College of
Physicians. He was a member of the Cen-
| tral Society for Clinical Research, the
Central Research Club, the American So-
ciety for Clinical Investigation, The Col-
lege of Physicians of Philadelphia, the
Physiological Society of Philadelphia, the
John Morgan Society of the University of
Pennsylvania, and the American Society
of Nephrology, among others. He was the
author of more than 60 papers in the

general topics of renal physiology, clinical
medicine and clinical pharmacology.

Throughout his career, Dr. Crosley was
well liked and respected by his many
colleagues. It was a great pleasure to work
with him and try to emulate his cheerful
persistence in the face of difficulty. No
chore was too difficult or menial for Dr.
Crosley to tackle with his characteristic
vigor.

In addition, he was a deeply religious
man. He was an elder of the Neshaminy-
Warwick Presbyterian Church at Harts-
ville, Pennsylvania, and while at Wiscon-
sin was active in the foundation of the
Covenant Presbyterian Church. He is sur-
vived by his wife, the former Frances A.
Davis, and three children, Mary C,
Barbara A. and Archer P., Ill, and his
father, Archer P., Sr. Dr. Crosley lived a
short life but managed to pack a great
deal of solid achievement into his 47 years.
All of us who knew him have profited by
so doing.

Memoir of Andrew J. Donnelly
1910-1968*

By PAUL J. GROTZINGER, m.d.

ANDREW J. Donnelly, m.d., was born
J-\ November 26, 1910, in Philadelphia.

"^He attended Villanova College from
1929 to 1932 and received his M.D. from
Temple University School of Medicine in
1936. Following an internship at St. Agnes
Hospital from 1936 to 1937, he became
chief resident at that hospital until 1939.
Starting in 1940, he was acting Assistant
Pathologist at the American Oncologic
Hospital, except for the time spent at the
Lankenau Hospital, where he finished his
residency in pathology under the late Dr.
Stanley P. Reimann. He became Patholo-
gist to the American Oncologic Hospital in
1943 and held this position until the time
of his death. His interest in the study of
tumors led quite logically into experimen-
tal work at the Institute for Cancer Re-
search, which he joined in 1945, becoming
Chairman of the Division of Pathology in
1960. In addition, he held an appointment
as Professor of General Pathology at
Temple University School of Dentistry.
He was a Diplomate of the American

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

Board of Pathology, having been certified
in 1944. He was author or co-author of a
large number of publications, most of
which were concerned with cancer re-
search. He was active in professional so-
cieties and held the office of president of
the Pennsylvania Association of Clinical
Pathologists and of the Philadelphia
Pathological Society.

Outside of his professional life, he was
an avid sports enthusiast and actively par-
ticipated in tennis and, more recently, in
trap shooting. He was widely read, having
a particular interest in dramatic literature
and in the theater. At one period in his
life he was active in oil painting.

He was married to the former Elizabeth
Moran and is survived by her, their two
children, Frances and Patricia, a brother,
Patrick, a Maryknoll missionary priest
stationed in Taiwan, and two sisters,
Margaret Donnelly and Sister Marie
Thomas, s.s.j.

He died November 7, 1968, of an acute
myocardial infarction. He was a man who
took great satisfaction from the practice
of his chosen profession and from research
and teaching.

88

Memoir of Francis Clark Grant
1891-1967*

By ROBERT A. GROFF, m.d.

With the sudden death of Francis Clark
Grant, a void occurred in the field of
neurosurgery and among his associates,
pupils and friends. Dr. Grant spanned the

1 period between the pioneers in neuro-
surgery to the present well-trained neuro-
surgeons with their sophisticated tech-
niques. He received his training from the
masters — Dr. Charles H. Frazier and Dr.
Harvey Cushing — and succeeded Dr. Fra-
zier as Professor and Chairman of the
Department of Neurosurgery of the School

i of Medicine and Hospital of the University
of Pennsylvania in 1936. He held this
position until 1953 when an untimely ac-
cident fractured his hip and right thumb,
forcing him to retire three years before the
statutory age.

Dr. Grant was born in Philadelphia on
November 9, 1891, the son of William
S. Grant, Jr., and Jane Burnham Clark.
He received his early education in Phila-
delphia and then entered Groton School
at the age of 13. Because he was well-
nourished, his fellow classmates gave him
the nickname "Chubby," which was

1 adopted by all his friends. He was gradu-
ated in 1910 and entered Harvard College
where he made a host of life-long friends
and developed into an excellent middle-
weight boxer. Upon completion of his col-
lege training, he sailed on a mission boat
for Dr. Grenfell along the coast of Labora-
dor. He then entered the School of Medi-
cine of the University of Pennsylvania and
was graduated in 1919 among the top men
of his class.

• Read before The College of Physicians of Phila-
delphia, 4 December 1968. Prepared and published
at the request of the Council of The College of
Physicians of Philadelphia.

During his medical school days in 1917,
Dr. Grant married Anne Lewis. They had
five children, three of whom are still liv-
ing: Nancy, Francis, Jr., in the Diplomatic
Service, and Joseph, who is Chief of Medi-
cine at the Veterans Administration Hos-
pital in Vermont.

Following a two-year internship at the
Hospital of the University of Pennsyl-
vania, he became an apprentice to Dr.
Frazier. In those days, the residency pro-
gram as it is known today had not been
established. His talents were quickly recog-
nized so that by 1928 Dr. Grant was ele-
vated to the position of Assistant Professor
of Neurosurgery in both the School of
Medicine and the Graduate School of
Medicine. Up to this time, he had spent
part of a year — 1925 — with Dr. Harvey
Cushing at the Peter Bent Brigham Hos-
pital in Boston as a clinical clerk. In
1935, he was promoted to Professor of
Clinical Neurosurgery in the Graduate
School of Medicine and, in 1936, he suc-
ceeded his chief, Dr. Frazier, as Professor
and Chairman of the Department of
Neurosurgery in the School of Medicine.

Dr. Grant wrote many papers, of which
some 226 or more have been published. His
writings are characterized by clarity of
thought, a crisp, clear style and especially,
a "to-the-point" evaluation of the problem.
The paper which best exemplifies this is
the one entitled, "A Study of the Results
of Surgical Treatment in 2,326 Consecu-
tive Patients with Brain Tumors." This is
an outstanding evaluation of the results of
surgery in brain tumor patients and repre-
sents a monumental contribution. He con-
cluded from this study — 659 of these pa-

89

90

ROBERT A. GROFF

tients having lived for from 5 to 30 years —
that in a patient who has a removal-type
tumor one should "put to work the very
best and most experienced team the clinic
can assemble."

One of Dr. Grant's hobbies was the
taking of photographs of various lesions of
the brain and spinal cord. Very early, he
recognized the effectiveness of color pho-
tography. As a result, he accumulated, to
the best of my knowledge, the most out-
standing collection of color slides of surgi-
cal lesions of the central nervous system.
He used these freely in his lectures and his
apt and concise technique of lecturing
made him one of the most popular lec-
turers in the School of Medicine. The
students knew him as the distinguished
character of the Corn Cob Pipe.

The training of men for the practice
of neurosurgery was a major interest of
Dr. Grant. When the American Board of
Neurological Surgery was established in
1937, he became one of the members.
In 1952, he became Board Chairman. He,
therefore, played a leading role in formu-
lating the training program for residents
in neurosurgery as it is today.

During World War II, Dr. Grant gave a
short course to Army Medical Officers on
the treatment of brain, spinal cord and

peripheral nerve injuries, in spite of the
added work load created by younger neuro-
surgeons entering the service. Nearly 100
officers took this course. In addition, dur-
ing his teaching career, he trained over
30 physicians for the practice of Neuro-
surgery.

Dr. Grant was a member of all the
major neurological and surgical societies.
In 1951, he was elected an honorary mem-
ber of the Italian Neurosurgical Society —
Societa Italiana di Neuro-chirurgia. He
was a member in one capacity or another
of 27 hospitals in this area.

Dr. Grant died of a coronary thrombosis
in the University Hospital on November
20, 1967. Just the day before his death, he
gave my senior resident a lecture on the
qualifications of a good neurosurgeon.

To those of us who were close to Dr.
Grant, he will always be remembered for
his inspiring personality, his passionate de-
sire for truth, his frank, outspoken state-
ment of facts, his profound desire for per-
fection of not only surgical technique but
also patient care, and for his love of teach-
ing students and training men to become
better neurosurgeons.

To me, Dr. Grant was a particular in-
spiration and I owe much of what I have
accomplished to him.

Memoir of William E. Krewson, III

1908-1968*

By EDMUND B. SPAETH, m.d.

WILLIAM E. Krewson, III, m.d., a
distinguished Philadelphia oph-
thalmologist, respected by all his
colleagues and beloved by those who knew
him intimately, died recently after a second
massive coronary attack.

The first attack occurred several years
. ago, and it was thought that his recovery
from this was complete and permanent. It
is difficult to reconcile these coronary at-
tacks with his gentle disposition, his
kindly, generous attitude to all his con-
tacts, and the apparent absence of any
mental stress or strain, except as surmised
by a few of his intimate friends.

Dr. Krewson was the only son of William
E. Krewson, Jr., and Etta May Shoemaker,
both long-time residents of Germantown.
His father was a druggist, much better
described as a pharmacist, with his phar-
macy in the Mt. Airy area of German-
town until his death. Dr. Krewson was
graduated from Germantown High School
in Philadelphia in 1926 and went on to
Wesleyan University in Middletown, Con-
necticut, from where he was graduated
with honors in 1930. Following his gradu-
ation, he was active in alumni activities
of Wesleyan University for many years,
especially on behalf of potential scholar-
ship candidates from the Philadelphia
area.

He was graduated from the University
of Pennsylvania School of Medicine in
1934 and completed a rotating internship
in the Allentown General Hospital. It is
quite proper to say that they turned out a
very fine physician. It is interesting that

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

at the end of his internship his greatest
field of inquiry was obstetrics and gyne-
cology.

Between the time he completed his in-
ternship and his start in postgraduate
medical study, he became interested in
ophthalmology. In retrospect, it seems that
tli is was probably the result of the long-
time friendship which existed between
Dr. Luther C. Peter and his father. In
1935, he took the Basic Science Course in
Ophthalmology at the then Graduate
School of Medicine of the University of
Pennsylvania. The chairman of the De-
partment of Ophthalmology at that time
was Dr. William T. Shoemaker, who also
shared in the formation of Dr. Krewson's
decision to enter ophthalmology.

Following his completion of the basic
science course and his qualification for a
Master of Medical Science degree in Oph-
thalmology, he entered private practice
with Dr. Luther C. Peter and continued in
association with him until Dr. Peter's
death. Following that, Dr. Krewson con-
tinued in the private practice of oph-
thalmology, taking over the practice of
Dr. Luther C. Peter.

Dr. Krewson continued actively in post-
graduate teaching in the Department of
Ophthalmology in the Graduate School of
Medicine until his death, reaching the
rank of Associate Professor.

Early in his practice, he became most
interested in oculomotor disturbances and
soon became a well-known and acknowl-
edged American authority. His associa-
tion with the Orthoptic Council of Amer-
ica was evidence of his excellence in this
field of ophthalmology.

91

92

EDMUND B. SPAETH

Also, early in his postgraduate practice
he joined the clinical service of Dr. Ed-
mund B. Spaeth at the Wills Eye Hospital,
and from there rose through the ranks of
staff appointments and promotions to
reach the positions of Attending Surgeon
and Chief of Ocular Motility at the Wills
Eye Hospital, positions he held at the
time of his death.

His contributions to the literature of
ophthalmology and ophthalmic motility
were all beautifully written and well re-
ceived. He was meticulous in his study of
his cases and always willing to present

and discuss these with the residents, with
his associates and with referring oph-
thalmologists. By his death, Philadelphia
ophthalmology and American ophthalmol-
ogy lost a dedicated, mature ophthalmolo-
gist, and the Wills Eye Hospital lost a
staff member of outstanding stature. His
wife, the former Mary Britz, is his only
survivor.

The writer lost a dear friend and an
esteemed associate from the time that he
was a student in the Graduate School of
Medicine until his demise. He was, in
every sense of the word, a gentleman.

Memoir of William Harvey Perkins
1894-1967*

By THADDEUS L. MONTGOMERY, m.d.

WILLIAM Harvey — the name sa-
vors of medical tradition. We re-
call the English anatomist, born
at Folkstone, England, April 1, 1578,
graduate of Cambridge, student of medi-
cine under Fabricus, Casserius and Gali-
leo; author, scholar, discoverer of the
circulation of the blood.

1 have sought to trace a connection be-
tween the names of these two medical
scholars, so highly regarded in their re-
spective generations, but there appears to
be none. Harvey was the mother's family
name, and William, of course, a common
title. However, someone inadvertently
hung above our William Harvey's cradle a
star, which he gazed upon, and under the
effulgence of which his career evolved
and expanded and in a modest way ap-
proached that of his famous progenitor.

William Harvey Perkins was born in
Germantown, Pennsylvania, on October
21, 1894, the son of Penrose Robinson and
Mary Harvey Perkins. From an early age
he manifested interest in science and a
desire to become a medical missionary. In
this direction he was undoubtedly nurtured
by his uncle, E. Newton Harvey, Henry
Fairfield Osborn Professor of Biology at
Princeton University, and by his own read-
ing of the lives of Stanley and Livingstone.

He was educated at the Germantown
elementary schools and Central High
School. In 1913, at the age of 19, he en-
tered the Jefferson Medical College. He
served an internship at Jefferson Hospital
and did his stint of military duty in World

* Read before The College of Physicians of Phila-
delphia. 4 December 1968. Prepared and published
at the request of the Council of The College of
Physicians of Philadelphia.

War I as First Lieutenant in the Medical
Corps of the U. S. Army at Base Hospital
#120 in Tours, France.

Incidentally, his classmates and friends
in medical school had made short shrift of
his surtitle, William Harvey, and labeled
him "Cy" after a similarly-built, lanky and
amiable comedian at Keith's Vaudeville
Theatre on Chestnut Street, who sang
songs and cracked jokes about "Cy Per-
kins, the farmerman." The name stuck the
remainder of Dr. Perkins' life. Thus, the
mighty became subject to the common
place.

On return from France, "Cy" married
Barbara Isabelle Bond of Germantown,
and without further delay the two set
forth together upon a life's work. He se-
cured in 1918 an appointment as Medical
Missionary to Siam under the Presbyterian
Board of Foreign Missions. In the interior
of Siam for four years, he dispensed health
education and medical treatment under ex-
traordinarily difficult conditions. Without
the companionship of a courageous wife,
he would never have survived. Mind and
spirit were always far ahead of a not too
rugged constitution. The victim of malaria
and a succession of tropical boils, he was
finally forced to return to this country to
recover health.

The Rockefeller Foundation provided
a sabbatical leave during which he visited
schools of public health and spent a year
in the medical service of Thomas McCrae
at Jefferson. This experience and the sev-
eral years in the back country of Siam
undoubtedly set the stage for his notable
career in public health and preventive
medicine.

In 1926, through a cooperative arrange-

93

94

THADDEUS L. MONTGOMERY

ment of the Rockefeller Foundation and
the Government of Siam, he returned to
Bangkok as Professor of Medicine in the
Royal Medical School of Chulalangkarana
University and Physician to the Govern-
ment. In these positions he served witli
distinction until the termination of serv-
ices of all foreign teachers in 1931. At this
time, the King of Siam conferred upon Dr.
Perkins the highest honor of his country,
the Order of the White Elephant.

In June 1931, Dr. Perkins was appointed
Instructor in the Department of Medicine
of Tulane University School of Medicine
and the next year Professor and Head of
the newly organized Department of Pre-
ventive Medicine. From this position he
resigned in 1941 to accept the Deanship
of Jefferson Medical College and the
Chairmanship of the Department of Pre-
ventive Medicine.

The return of William Harvey Perkins
to his alma mater was an important event
in the history of that institution. The
morale of the college was low, its aca-
demic reputation had ebbed and its leader-
ship was uninspired. The new dean
brought clear vision of what the institu-
tion should be, a scholarly approach and
inspiring leadership.

His activities were not confined to re-
vitalization of the Jefferson Medical Col-
lege but extended to the growing health
problems of Philadelphia. He is credited
with the planning of the ten District
Health Centers of Philadelphia. He
chaired for many years the Health Divi-
sion of the Health and Welfare Council of
Philadelphia.

Dr. Perkins was active in the affairs of
The College of Physicians, particularly in
the Section on Public Health and Pre-
ventive Medicine. The College honored
him by establishing the William Harvey
Perkins Prize for the best essay on Pre-
ventive Medicine written by a student of
any one of the five medical schools of
Philadelphia.

Dr. Perkins enjoyed writing poetry about
his children and grandchildren, prose con-
cerning the incidents of his life in Siam,
and treatises on subjects of public health
and preventive medicine. The former re-
main unpublished, but the latter are well
recognized articles and texts, including
Cause and Prevention of Disease (Lea and
Febiger, Philadelphia, 1938, 748 pp.) and
Obstetric Medicine (Edited by Fred L.
Adair and Edward J. Stieglitz, Lea and
Febiger, Philadelphia, 1934, Chapters X
and XI).

His scholarly career and high position
brought many responsibilities and many
honors. These included membership in the
following societies:
American Medical Association
American Society of Tropical Medicine
American Public Health Association
National Tuberculosis Association (Re-
gional Director)
American Red Cross, Home Hygiene

Division, (Chairman, 1938, to date)
Orleans Parish Medical Society
Louisiana State Medical Society (Chair-
man, Section on Public Health, etc.,
1941)

New Orleans Academy of Sciences (Sec-
retary, 1939, to date)

New Orleans Council of Social Agencies
(President, 1941)

New Orleans Mental Hygiene Associa-
tion (President)

Louisiana Society for Mental Hygiene
(President)

Social Hygiene Association of New
Orleans (Vice President)

Member, Board of Directors, Philadel-
phia Tuberculosis and Health Associ-
ation

Association of Spanish-Speaking Physi-
cians

The Medical Club of Philadelphia
Theta Kappa Psi Medical Fraternity
Alpha Omega Alpha Honorary Medi-
cal Fraternity

MEMOIR OF WILLIAM E. KREWSON, III

').-)

Council of Social Agencies
Community Fund
Foreign Policy Association
Fellow, American College of Physicians,
1942.

What mainly attracted his friends as
they grew older with him were his in-
dividual attributes. He was a friendly per-
son; he possessed a scholarly mind; he
pursued his speciality in medicine with en-
thusiasm; he led his Faculty of Medicine
in t he paths they would follow; and he

took time to encircle his wife, his children
and his grandchildren with love.

Failing health forced Dr. Perkins to
resign the arduous duties of Dean in
November 1950 and of Professor of Pre-
ventive Medicine in 1959. He died on
October 22, 1967.

The Scripture says, "Blessed are the
meek, for they shall irdierit the earth."

I should like to add, "Blessed are the
intelligent, for they may some time prevail
on earth."

Memoir of William Whitaker
1880- 1968*

By FREDERIC C. SHARPLESS, m.d.

IT is a pleasure to pay tribute to a
doctor who left a reputation of un-
usual medical ability and of compas-
sionate service to his patients and yet was
too modest to advertise his good works.
His self-effacement was proverbial.

William Whitaker, m.d., was born in
Philadelphia on August 7, 1880. His fore-
bears had emigrated from England to this
country in 1814 and his father was the
founder of a cotton mill nearby. His son
was graduated from the University of
Pennsylvania School of Medicine in 1903,
being one of the youngest in his class. He
felt that he owed more to Dr. D. J. Mc-
Carthy, his quiz master, than to any of
the regular members of the faculty. Like
his classmate, Walter George Baird, he
developed tuberculosis at the medical
school, but, unlike Baird, he recovered
with the loss of eight years' work. When
able to resume work in 1914, he opened
an office at 5448 Germantown Avenue and
lived the life of a general practitioner or
family doctor for about forty years. He
was associated at first with the revered Dr.
Howard Fussell at St. Mary's Hospital
and later with the Episcopal Hospital.
Here he met a life-long friend, Dr. A. P.
C. Ashhurst.

In 1910, he was married, and Mrs.
Elizabeth B. Whitaker still survives. There
are no children and Mrs. Whitaker, charm-
ing and intelligent, devoted her time to
furthering her husband's success. He de-
veloped no specialty; he treated rich and
poor alike, all of whom held great affection
for him as a skillful doctor and warm

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

friend. His modesty prevented any medi-
cal writing for publication. His wife says
that he was far more interested in cure
than in finance.

In 1917, the crowning period of his
career came with the World War I.
Through the influence of Dr. Ashhurst,
he obtained enlistment in Pennsylvania
Base Hospital #10 with the rank of first
lieutenant. Here he served in the surgical
section for twenty months and in the British
General Hospital #16 until his discharge
at Camp Dix on April 22, 1919, with the
rank of captain. He had valued very highly
his association in France with Charles F.
Mitchell, surgeon (later his surgical consult-
ant in Germantown), his room-mates, Frank
Knowles, dermatologist, and the beloved
Howard Cloud, practitioner in Ardmore,
now deceased. Also there were James R.
Cameron, dental surgeon, and many other
members of Base Hospital #10 staff. His
only and probably favorite recreation was
to go on walks with his old companion in
arms, Dr. Cloud.

Dr. George Wilson used to tell us that
where there is somatic illness there is
usually mental illness as well. Before the
advent of the sulphas, all honest doctors
knew that their presence in the sick room
did the patient more good than their bad-
tasting medicine, and I am sure that the
visits of a man like Dr. Whitaker did not
become any less welcome with the advent
of the newer drugs.

The writer once attended Dr. Whitaker
professionally after his retirement and,
after two weeks of contact with him, it was
easy to explain why such an aura of ex-
cellence had always surrounded him. Dr.

96

MEMOIR OI W ILLIAM WHITAKER

97

|olin H. Wolf, surgeon to the German-
town Hospital, had this to say, and he said
it with enthusiasm: "Dr. Whitaker was the
most loved man I have every known. He
was quiet and gentle, with a keen diag-

nostic sense, most unassuming and modest.
No one could have at tended to his work
more faithfully and with more efficiency
and kindness. He was worshipped by his
patients."

TRANSACTIONS V STUDIKS

"f ^

The College of Physicians of Philadelphia

Volume 37
(Fourth Series)

Number 2
(October 1969)

Dr. William Bryant (1730 86): American
Physician and Antiquary 1

r,\ I RED B. K( )GI RS, m.d. 2

A FINE contemporary portrait of Dr.
Willi. mi Bryant, an 18th-cenlur\
tenant ot the historic William
I urn I louse at Trenton, \. |.. dire< is
toda) 's \ iewei ba< k to I he remai kable life
ami limes of its subject. The Chevalier
Bryant, .is this French-trained physician
was sometimes called, was a well-educated
and widely-travelled man who participated
in tumultuous events during the American
Revolution. A cultured and wcahln pei-
son, he combined medical practice with in
terests in natural science and antiquarian
lore (1).

W illiam Bryant was born in New York
City on 3 January 1730/31, son of Captain
William Bryant and tleanoi his wife, and
eight days later was baptized in the First
Presbyterian Church there. Captain F»i\-
ant. according to the words on the tomb
stone his son elected in 1772 in St. Peter's
Churchyard, Perth Amboy, N. J., "in 55
voyages, in the Merchant Service between
the Poi ts of New York and London, ap-
proved himself a faithful and fortunate

'Kate Html Mead Lecture in Medical History
\\. Woman's Medical College of Pennsylvania and
Section on Medical History, The College of Phy-
sicians of Philadelphia, 15 April 1969.

- I emple University School of Medicine, Phila-
delphia, Pennsylvania 19140.

tder." Captain and Mrs. Bryanl
look pride in then seven children: \l a i \ ,
the oldest, born in I Tl'l. (tossed the ocean
with her lather and was tutored in London
l)\ the Rev. Isaac Watts beloie she re-
turned to many William Peartree Smith,
who became mayor of Kli/abeth, N. [.;
Martha, wed to the Rev. Lorenz T.
Nyberg. a Swedish Lutheran ministei <»l
Lancaster, Pa., latet died a widow in Hng-
Land; Rebecca, married Captain Le Cheva-
lier Deane, an eminent citizen ol Charles-
ton, S. C: William, studied medicine, as
did his \ounger biother. Joshua, who
practiced on the West Indian island ol
Grenada; Elizabeth, was the wile ol the
Rev. Benjamin Woodruff, pastoi ol the
Presbyterian Church ai Westfield, N. J.:
.mil Ebenezer, the youngest, born in 1736,
tcad law and practiced in Klizabcth, N. J.

(2)-

William Bryanl was graduated B.A.
from Yale College in 1717: a decade latei
he received its M.A. degree (3). As Paris
excelled as a centei foi surgical stud) up
to the time ol John Hunter, Bryant
travelled to France to acquire professional
skill. [Other Americans who studied at
Paris or Rheims during this period were
Drs. Thomas Cadwalader (1708-79),

99

inn

FRED B R.OGI l<s

Fig. I. Portrait of Dr. William Bryant, now hang-
ing in The William Trent House, Trenton, N. J.
Attributed to Matthew Pratt (1734-1805), a pupil of
Benjamin West. Oil on canvas, 24 x 29", circa 1776.
The original ownci ol iliis portrait was Elias Boudi-
not, a friend and kinsman of Dr. Bryant.

Phineas Bond (1717-73), and John Joins
(1729-91), all of whom became eminent
practitioners in Philadelphia.] Greal
French surgeons of this era included
Henri-Francois Le Dran, famed lit hot-
omisi. |ean-Louis Petit, inventor of in-
struments and procedures, and Jean-Joseph
Sue. surgeon and teacher of surgeons. The
Academic RoyaJe dc Chirurgie, founded at
Paris in 1731, was an organization in
which these men collaborated.

Dr. Bryant settled for practice in New
York City. He remained there until 1769,
when he purchased for £2,800, by deed
dated 28 October, an estate called Kings-
bury at Trenton. Built fifty years earlier
by the town's founder, William Trent, a
native of Inverness, Scotland, the house
and "plantation" was situated at Little-

bow, where the Assunpink Creek entered
the Delaware River at its tidal falls (4). A
contiguous properly was owned In Dr.
Thomas Cadwalader, a Quaker physic ian
who lived lrom I iiiu -lo t ime at Lamheiion,
his wile's family seat south of the town. Dr.
Cadwalader resided at Trenton from 1743
to 1750 and was its first chief burgess or
mayor under royal charter in 1745-40. He
founded the Trenton Library Company by
a gift of £500 in 1750 — New Jersey's first
"public" library. Returning thereafter to
his native <it\ ol Philadelphia, in 1709 he
was chosen a vice-chancellor of the Ameri-
(.iii Philosophical Society, an office he
filled until his death on 14 November
1779. His body was interred in the Han-
over Street Friends Meeting burial ground
in Trenton (5).

Dr. Bryant and his wile, Mary, went to
Philadelphia occasionally on business and
to visit the doctor's niece, Mary, and her
husband, Dr. Samuel Dufheld (1732-1814).
Miss Sarah Eve (1750-74), a young lady
who died while engaged to be married to
l)i Benjamin Rush, met Mrs. Bryant at
the Duffields on 2 November 1773 and
wrote an uncomplimentary impression of
her in a later-published diary (6). De-
scribed as arrogant, domineering and
stingy, Mary Bryant remained childless
and, by 1779, was losing her eyesight. For
these reasons, perhaps, the Doctor sought
affection elsewhere. Charity Murrow of
Trenton bore him a "natural" son, also
named William Bryant, who was acknowl-
edged and generously provided for by his
father.

At Dr. Duffields prompting, Bryant
wrote out his observations on the electrical
eel which he had made on a short visit to
Surinam, a Dutch colony on the northeast
shoulder of South America. Dufheld read
the report to the American Philosophical
Society at Philadelphia on 5 February
1773. As this was a time when electrical
phenomena were new and fascinating, the
electrical eel excited a great deal of atten-

DR WILLIAM HIM \\ I

I'll

Fic. 2. The William Trent House, Trenton, as it appears today. I5uilt in 1710 for Chief
|iisiu c \\ i lli. ii i] I i cm ol New |( 1 sc\ , w ho died then in 1 71! I il u as the houii "I l)i anil \l i s
William Bryant from 1709-78. Opened to the public as a museum in 1939.

(ion. Bryani described his tests, which in-
dicated that the eel's discharges were simi-
lar to those of common electricity. He
noied that altei a period ol confinemenl
(his "extraordinary animal" lost much ol
its electric strength, but that when pro-
voked, iis impact revived. Bryant received
several "\er\ small shocks" lor his curios-
ity. The report won him election to the
American Philosophical Society on 21
Januar) 177 1. I he papei was published in
1786 .is Communication No. 12 of Volume
2 ol i he Society's Transactions ("Account
ol an Electrical Eel, or the Torpedo of
Surinam, b) William Bryant, Esquire",
pages 166-169). There is no record that its
author ever attended a meeting ol the
Society; the secretary sent him a member-
ship certificate in January 1786.

During the War ol Independence, Dr.
Bryant evidenced Tom sympathies. His
name appeals as a hall-pay surgeon on
the rolls of the New Jersey Volunteers, a
Lo\alis( regiment raised In General Cort-
landt Skinner in 1776 (7). On 23 January
1776, the Burlington County Committee of
Safety, suspecting that Bryant might be
planning to join the British Army at
Boston, plated him on parole; later this
was extended to thirty miles to permit him
to \isit Princeton, where he had patients,
and Philadelphia, where he had relatives.

Shortly before the Battle of Trenton,
Bryani warned Colonel fohann Gottlieb
Rail, commander of the Hessian detach-
ment stationed there, of an impending
attack l>\ General Washington's army — a
warning ignored by the overconfident

102

I KI D II !<()(,! RS

mercenary. Gener;il William S. Sitykcr told
this anecdote in his book. The Battles o)
Trenton and Princeton, |>iil>l i-.Ii<-< I in 1808

(8).

On Monday morning, December 23, at eleven
o'clock, I .iriiteiKint Ernsl Christian Schwabe ol the
von Lossberg regiment met mi king Street l>i
Willi. mi tin. mi, the physician who lived on the
Kingsbury Farm, and who was seeking Colonel Rail.
Km k.ill could not in Eound thai morning, and Dr.
Bryant left Lieutenant Schwabe with 1 1 it- piomise
that lie would return l.ilci in llic <l;iy. He did mi,
and then told Colonel Rail thai he had just heard
from a Negro who had crossed the river that the
rebels had drawn rations foi sc\eral d.i\s, and were
about to attack Trenton. "Ihis is all idle (hatter!
It is old women's talk." imp. it ieul 1\ answered Colo-
nel Rail. Rut the doctor, who was aliaid ol In 1114
lobbed and having his house binned took tin mailt 1
more sei iotish .

Dr. Bryant's house, iclerred to in lies
si, in records as the "Doctor Hauss," over-
looked an important Delaware Ki\ei leitv
(siic ol todays Pent) Central Railroad
bridge). A picket patrol was maintained In
Hessian sentries between the ferry and the
"Caserne" or militai\ banacks in the town.
I he doctoi attended soldiers living in
whai is tod, w called the Old Barracks — a

stone structure built in I7.">8 to <|ti.iitei
British Hoops dining the French and In-
dian War. (Restored as a museum, the Old
Barracks, located on the state Capitol
"rounds at I teuton, was opened to the
publi< in 1917.)

1 here were tea 1 1 \ two battles of Tren-
ton the dramatic sin prise of the Hes-
sians. 2(i December 177b. and the Battle
of the Assunpink. 2 January 1777. In the
first battle, at a cost of none killed, Eoui
wounded, but two ho/en to death, the
Americans captured over 900 prisoners,
1200 small arms, 6 brass cannon and i he-
colors of the Hessian brigade. (The Hes-
sians lost 35 killed, including their com-
mander and 60 wounded. Generals Wash-
ington and Nathanael Greene spoke with
the mortally-wounded Rail and in re-
sponse to his request assured him that the

prisoners would receive kind treatment.)
In the second battle, following a signili-

< .iiit delaying action in which British
troops nuclei General Cornwallis were re-
pulsed ai the Assunpink Creek, Washing-
ion left his camp lues burning and altei a
bold night march scored anothei \ittoiy
al I'lincelon. The 1 renton-Pi hit eton cam-
paign marked the turning point ol the W ar
of Independent e.

I he- Kingsbury [arm was a part ol eath
engagement al [renton. Following seizure
ol the stone- bridge ovci the Assunpink by
the Americans in the first battle. Colonel
Daniel Hitchcock's brigade threw up tem-
porary breastworks on the high ground
along the south side ol the creek on the
Doctor's land. I he subsequent British as-
sault on the strategic bridge was repulsed
from this vantage point. Though knows
to be friendly with the Hessians, Dr.
Bryant was not molested by the patriots!
His professional value apparent!) over-
shadowed political differences and he at-
tended casualties on each side of the con-
Bi< t.

Also during the war, Bryant met his
partner and successor in practice, Dr.
Nicholas de Belleville (1753-1831). A na-
tive of Metz, France, trained as a surgeon
in Paris. Belleville tame to America with
the Polish Count Casimh Pulaski as medi-
cal officer to his legion. W hile camped at
Trenton in 1777. Dr. Belleville met Dr.
Bryant, who treated him cordially and en-
couraged him to enter into partnership.
Following the death of Pulaski in battle,
Belleville returned to Trenton late in 1778.
The New Jersey Assembly, in minutes
dated 7 October 17iS0, appropriated £4, 1
s., 3 d. to Drs. Bryant and Belleville "foi
medical attendance on Enoch Anderson,
taken sick in service, June 1780" (9). Again,
on 25 October 1787, after Dr. Bryant's
death, a petition to the Orphans' Court by
John Langstaff and his wife Charity
stated: "That the said Charity is the
mother of a child named William Bryant,

DR. WILLIAM BRYANT

103

to whom Dr. Wm. Bryant left a considera-
ble legacy; the acting Executor being
dec'd, they petition that Dr. Nicholas
Belleville may be appointed Guardian of
said Child" (10). Dr. Belleville, who served
as the boy's guardian until September
1794, remained at Trenton for the rest of
his life — esteemed as a physician and the
progenitor, through his daughter, of a re-
markable line of descendants.

During Dr. Bryant's residence at Kings-
bury, the farm yielded a rich variety of In-
dian artifacts — stone hatchets, chisels,
pestles, arrowheads, a pot with handles
shaped like a porringer's, and a cup made
of asbestos-like material (11). The Unami
or turtle clan of the Lenni Lenape Indian
tribe had formerly been centered near the
falls of the Delaware River. Some of their
relics Bryant gave to Pierre Eugene du
Simitiere, another member of the Ameri-
can Philosophical Society, for the latter's
museum on Arch Street in Philadelphia.
The Swiss-born du Simitiere, antiquary,
naturalist, artist and designer of the Great
Seal of the United States, recorded a varied
correspondence with Bryant between 1776
and 1783 — concerning almanacs, curios of
nature, and weather observations (12). Du
Simitiere's collection, opened to the public
as the American Museum, remained intact
for only two years (1782-84). Having de-
voted his life to the assembling of material
and specimens for a natural and civil
history of America, it is unfortunate that
the General Assembly of Pennsylvania,
after du Simitiere's death in 1784, did not
deem it expedient to purchase and preserve

i his collection, refusal of which had been

J granted it in his will (13).

Another antiquarian link of Dr. Bryant
came through his friend and kinsman,
Elias Boudinot (1740-1821), a prominent

I New Jerseyman. Boudinot's younger
brother, Elisha, of Newark, married Bry-
| ant's niece, Catharine Smith, in 1778. Like
I William Penn, Quaker founder of Penn-
sylvania, and other earlier thinkers, Elias

Boudinot speculated about the origin of
the American Indians — believing them to
be possible descendants of the Biblical
Lost Tribes of Israel. A firm patriot,
Boudinot served as president of the Con-
tinental Congress, signed the Peace Treaty
of 1783 with Britain, and was a friend of
George Washington, who appointed him
director of the Philadelphia Mint (14).

In 1816 Boudinot had published at
Trenton a book, A Star in the West; or, a
Humble Attempt to Discover the Long
Lost Ten Tribes of Israel, Preparatory to
Their Return to Their Beloved City,
Jerusalem. As with the guiding star in the
east of the Christmas story, Boudinot con-
sidered the North American Indians to
have been divinely directed to the New
World. Although his scholarship was in
the tradition of many speculative writers
who had preceded him, Boudinot's book
climaxed the concept of an aboriginal
Amerindian connection with the ancient
Israelites. His work offered, among other
ideas, the theory that certain Hebrew
words phonetically resembled those of the
red man's vocabularies. Published twenty
years after the death of Dr. Bryant, his
name does not appear in A Star in the
West. Almost a century later, however, an-
other physician-naturalist of Trenton, Dr.
Charles Conrad Abbott (1843-1919), living
and working close to the Kingsbury farm
site, uncovered more solid evidence of the
aboriginal people in the Delaware Valley.

Dr. Bryant was a man of considerable
wealth — real and personal property and
servants. The Pennsylvania Gazette of 28
December 1772 listed two servants, "Henry
Keyuts & Baltzar his son, late of Rotter-
dam," bound by indenture to Dr. Bryant
at Trenton before Mayor John Gibson of
Philadelphia (15). In the Doctor's will,
probated in 1786, he bequeathed "all my
Negro slaves except the boy William and
the girl Peggy" to his widow — with the
charitable proviso that none of them shall
"be sent off to or sold in the West Indies

104

FRED B. ROGERS

contrary to their own will and consent"
(16). Again, in The Pennsylvania Gazette
of 9 March 1774, Bryant advertized for sale
or lease "a number of building lots in
Kingsbury, on east and west sides of
Broad Street and north side of Delaware
Street, leading to the river, . . . most de-
lightfully situated, the soil exceeding good
for gardening, and excellent water may be
had at a moderate depth" (17).

In October 1778, Colonel John Cox of
Burlington, ironmaster at Batsto and a
Revolutionary soldier, purchased Kings-
bury Hall and changed the name of the
brick mansion to "Bloomsbury Court."
During the residence of Colonel and Mrs.
Cox and their six daughters, General and
Mrs. Washington, the Marquis de Lafay-
ette, the Comte de Rochambeau and other
notables visited this charming home. Dr.
Bryant, who moved to smaller quarters in
Trenton, gradually withdrew from medical
practice. A separate release by Mrs. Bryant
on a real estate sale, dated 8 February
1781, and executed more than three
months after the deed of her husband,
hints at a domestic disagreement, if not a
separation. The Doctor's final recorded
purchase of property in Trenton was by a
deed, dated 17 December 1783, conveying
to him a house and lot on the east side of
King (now State) Street (18).

General Cornwallis, the British com-
mander in chief, surrendered his forces to
a combined American and French force at
Yorktown, Virginia, in October 1781. After
the curtain fell at Yorktown the players
began to leave. It was two years, however,
before the lights were put out and the
theatre emptied by the departure of
British and Tories from New York City on
the famous Evacuation Day of 25 Novem-
ber 1783. Sir Guy Carleton completed the
evacuation of his red-coated garrison;
General Washington and his troops
marched in, and on 4 December, at
Fraunces Tavern, the American leader
bade farewell to his dispersing army and

rode south to spend Christmas at Mount
Vernon.

Dr. Bryant, described by Dr. Belleville
as elderly before age 50, did not choose to
leave his native land, as had numerous
other Loyalists. Sometime after 1783 he re-
turned to the city of his birth, New York.
His death, "of an apoplexy," on 11
January 1786, was noted in the First
Presbyterian Church register — which 55
years earlier had recorded his baptism. The
place of burial was not stated, but it was
probably in the burying ground surround-
ing the church on Wall Street. Mrs. Bryant
lived in comfortable circumstances in a
house on Crown (now Liberty) Street in
New York City until her death twelve
years later.

By his will, dated 28 October 1785, Dr.
Bryant left most of his property to his
widow (19). He further devised, "To my
natural son, William Bryant, by Charity
Murrow, £600, to be paid him when he
arrives at the age of 21 years; he to be sup-
ported by the interest arising from above
sum; he to be put to a trade and when he
has learned the same, £150 more to be
paid him in the setting up and carrying
on said trade; if my natural son should die,
£50 of the above sum to be paid to his
mother." Substantial bequests were made
to several nieces and nephews. To his
nephews, Belcher P. Smith and William
Pitt Smith, the Doctor bequeathed all his
books. He left £50 to his namesake, Wil-
liam Bryant Duffield, oldest son of Dr.
and Mrs. Samuel Duffield. [Dr. William B.
Duffield (1770-1841), who received an
M.D. degree from the University of Penn-
sylvania in 1790, also practiced in Phila-
delphia during his lifetime.]

In Mrs. Bryant's will, executed early in
1797 and proved 26 November 1798, she
remembered many friends, Negro servants,
and relatives (20). Among the kinfolk, she
left £200 to her husband's illegitimate son.
This gesture suggests that young William's
ways were winning — and that Mary Bry-

DR. WILLIAM BRYANT

105

ant's disposition had mellowed since that
day in Philadelphia when she played the
great lady in front of Sarah Eve.

REFERENCES

1. Wickes, Stephen: History of Medicine in New

Jersey and of its Medical Men, from the
Settlement of the Province to AD. 1800. M. R.
Dennis & Co., Newark, N. J., 1879, pp. 142,
170-171.

2. Jones, William Northey: The History of St.

Peter's Church in Perth Amboy, New Jersey,
the Oldest Congregation of the Church in the
State of New Jersey, from its Organization in
1698 to the Year of Our Lord, 1923, and the
Celebration of the 225th Anniversary of the
Parish; also a Genealogy of the Families
Buried in the Churchyard. Patterson Press,
New York, N. Y., 1925, pp. 222-224.

3. Dexter, Franklin B.: Yale Biographies and An-

nals, 2 vols. Henry Holt, New York, N. Y.,
1897, vol. 2, pp. 107-108.

4. Hall, John: History of the Presbyterian Church

in Trenton, N. J., from the First Settlement
of the Town. Ed. 2, MacCrellish & Quigley,
Trenton, N. J., 1912, p. 143.

5. A History of Trenton, 1679-1929. Two Hundred

and Fifty Years of a Notable Town with Links
in Four Centuries. Published, in Two Vol-
umes, under the Auspices of the Trenton His-
torical Society, Princeton University Press,
Princeton, N. J., 1929, vol. 1, p. 145; vol. 2,
p. 640.

6. Sarah Eve's Journal, in: The Pennsylvania Maga-

zine of History and Biography 5: 201-202,
1881.

7. Jones, Edward Alfred: The Loyalists of New

Jersey; their Memorials, Petitions, Claims, etc.
from English Records. The New Jersey His-
torical Society Collections, Newark, N. J., 1927,
vol. 10, appendix 3, p. 264.

8. Stryker, William S.: The Battles of Trenton

and Princeton. Houghton, Mifflin and Com-
pany, Boston, Mass., 1898, pp. 1 10-1 1 1.
9. Nelson, William (ed.): New Jersey Biographical
and Genealogical Notes. From the Volumes of
the New Jersey Archives, with Additions and
Supplements. The New Jersey Historical So-
ciety Collections, Newark, N. J., 1916, vol. 9,
p. 57.

10. Hutchinson, Elmer T. (ed.): New Jersey Ar-

chives, First Series, vol. XXXVII. Calendar of
New Jersey Wills, Administrations, etc.; vol.
VIII— 1791-1795. Jersey City, N. J., 1942, pp.
56-57.

11. Potts, William J.: Du Simitiere, Artist, An-

tiquary, and Naturalist, Projector of the first
American Museum, with some Extracts from
his Notebook. The Pennsylvania Magazine of
History and Biography 13: 361-363; 371-372,
1889.

12. Huth, Hans: Pierre Eugene du Simitiere and

the Beginnings of the American Historical Mu-
seum. The Pennsylvania Magazine of History
and Biography 69: 315-325, 1945.

13. Levey, Martin: The First American Museum of

Natural History. Isis 42: 10-12, April 1951.

14. Boyd, George A.: Elias Boudinot, Patriot and

Statesman, 1740-1821. Princeton University
Press, Princeton, N. J., 1952, p. 254.

15. The Pennsylvania Magazine of History and Bi-

ography 33: 488, 1909.

16. Hutchinson, Elmer T. (ed.): New Jersey Ar-

chives, First Series, vol. XXXVI. Abstracts of
Wills, vol. VII— 1786-1790. Trenton, N. J.,
1941, p. 33.

17. The Pennsylvania Gazette, March 9, 1774, p. 4,

col. 2.

18. Nelson (n. 9), p. 58.

19. The New-York Historical Society Collections,

New York, N. Y., vol. 14, Abstracts of Wills,
Liber 40: p. 91.

20. The New-York Historical Society Collections,

New York, N. Y., vol. 15, Abstracts of Wills,
Liber 42: p. 453.

Thomas Jefferson and the Doctors 1

By SAMUEL X

IT gives me great pleasure to address
this Greek-letter society which has the
humanitarian motto, "Worthy to
serve the suffering," and the Hippocratic
ideals as its goal. It is a special joy for me
lo return to Charlottesville, where Dr.
Robley Dunglison, the hero of my earlier
literary efforts, first established the medi-
cal school here in 1825 and won the im-
mediate esteem and affection of the Father
of the University of Virginia, Thomas
Jefferson. For this University had been
established by an Act of the Legislature
on January 25, 1819. Soon it will cele-
brate its sesquicentennial birthday. Even
though the Board of Visitors, during its
gestational period, had planned only two
professors, one to include anatomy among
his courses, on April 7, 1824, the Board
determined upon eight professors, and
stipulated that the School of Anatomy and
Medicine should teach anatomy, surgery,
the history of the progress and theories of
medicine, physiology, pathology, materia
medica and pharmacy. Out of eight years
of teaching here came Dunglison's monu-
mental works: his dictionary, his physiol-
ogy, a syllabus on medical jurisprudence,
his work on therapeutics, and others.

When I received the invitation to come
here, I pondered upon a fitting subject
for my talk. Several years ago Mr. James
A. Bear, Jr., Curator of the Thomas Jef-
ferson Memorial Foundation at Monticello,
showed me a manuscript, Medical Chro-
nology of Thomas Jefferson, which he had
diligently compiled, recording day by day

1 Annual Lecture in Medical History, Alpha
Omega Alpha, University of Virginia School of
Medicine, Charlottesville, Virginia, 4 November
1968.

2 7043 Elmwood Avenue, Philadelphia, Pennsyl-
vania 19142.

RADBILL, M.i).-'

and year by year medical events in the life
of our great President. It occurred to me,
since one of the objects of the Alpha Omega
Alpha is to "ennoble the profession of medi-
cine and advance it in public opinion," that
by presenting a glimpse of Jefferson's rela-
tionship with doctors I could in some small
measure help to achieve this aim.

It has often been said that Jefferson had
a lifelong contempt for physicians. In fact
he once remarked in the presence of Dr.
Charles D. Everett, private secretary and
family physician to James Monroe and
not partial to Jefferson, that whenever he
saw three physicians together he looked
up to discover whether there was not a
turkey buzzard in the neighborhood, im-
plying, I presume, that a consultation of
physicians was an omen of death. Yet
Jefferson counted a great number of doc-
tors among his most admired friends, as
much for his belief in the nobility of
their profession in the service of the suf-
fering as in his attraction toward many
of them for their social consciousness and
scientific achievements. "In my opinion,"
he once wrote regarding the study of
medicine, "no knowledge can be more
satisfactory to a man than that of his own
frame, its parts, their functions and ac-
tions."

To a young friend contemplating medi-
cine as a career, he expressed his opinion
concerning the practice of medicine in the
following words: "The followers of Escula-
pius are also numerous. Yet I remarked
that wherever one sets himself down in a
good neighborhood, not pre-occupied, he
secures to himself its practice, and, if
prudent, is not long in acquiring whereon
to retire and live in comfort. The physi-
cian is happy in the attachment of the
families in which he practices. All think he

THOMAS JEFFERSON AND THE DOCTORS

107

has saved someone of them, and he finds
himself everywhere a welcome guest. If,
to the consciousness of having saved some
lives, he can add that of having at no
time, from want of caution, destroyed the
boon he was called on to save, he will
enjoy, in age, the happy reflection of not
having lived in vain."

That Jefferson was a great skeptic con-
cerning much of the theory and practice
of medicine is common knowledge, yet,
through his opposition to the practice of
bloodletting and his objections to irra-
tional theories, promulgated throughout the
history of medicine, which could not be
scientifically proved or withstand the test
of time, he did help to moderate medical
. practice and direct medical research into
more logical and effective channels. Re-
garding false speculations, he once wrote
from Paris in 1788 to James Madison that
"it is always better to have no ideas, than
false ones; to believe nothing, than to be-
lieve what is wrong."

Bloodletting

It is hard to say just when Jefferson
developed his opposition to venesection.
People had faith in bleeding. They had
I themselves bled when they were well to
keep themselves well. This was an ancient
purification practice analogous in the
primitive mind to menstruation as a form
of periodic purification. Many physicians
argued against the practice through the
ages, but others pushed its use to great
extremes. It was done by the barber and
at the public baths, as often as a man took
a bath. Sydenham, the medical idol of all
good Englishmen of the eighteenth cen-
tury, in almost every disease started treat-
ment by opening a vein. But Pierre Louis
dealt the death blow to bleeding in 1835
when by means of medical statistics he
proved it worthless in pneumonia.

Long before Louis, however, Thomas
Jefferson did not permit it to be done in
l his family. His contracts with the over-

seers of his estate specified that an over-
seer was never to bleed a slave. He had
read LeSage, Smollett, Sterne, Fielding
and Moliere: all ridiculed the medical
practice of their time, and he must have
been influenced by their attitude toward
bloodletting. From Paris in 1786, Jeffer-
son wrote to Dr. James Currie: "Medical
science was demolished by the blows of
Moliere." Certainly the satires of LeSage
and Moliere cooled the passion of the
populace for venesection, but medical
theorists fortified the practice by many in-
genious arguments and a leading British
medical journal, founded shortly before
Thomas Jefferson died, is still called The
Lancet. After Louis' persuasive calcula-
tions, however, this magic wand lost its
healing power and within a decade or
two bloodletting was pretty well discarded,
although I must confess I was still taught
that it might occasionally prove useful.

Healing Powers of Nature and
Medical Theories

Jefferson, reading Sterne with his wife
as he nursed her in 1782 during her last
illness, apparently was impressed when the
author of Tristram Shandy declared that
"the physicians here are the errantest
charlatans in Europe, or the most ignor-
ant of pretending fools. I withdrew what
was left of me out of their hands and rec-
ommended myself entirely to Dame Na-
ture." Thenceforth, Jefferson firmly be-
lieved in the ancient doctrine of the "Vis
medicatrix naturae," the medical power of
nature. Thirty years later (1812) he wrote:
"While surgery is seated in the temple of
exact sciences, medicine has scarcely en-
tered its threshold. Her theories have
passed in such rapid succession as to prove
the insufficiency of all, and their fatal
errors are recorded in the necrology of
man." He also gave vent to his objection
to medical theories when planning the
curriculum of this' College. He wrote to
Dr. Thomas Cooper: "Perhaps I should

108

SAMUEL X RADBILL

concur with you also in excluding the
theory (not the practice) of medicine. This
is the Charlatanerie of the body as
theology is of the mind. For classical learn-
ing I had ever been a zealous advocate;
and in this, as in his theory of bleeding
and mercury, I was ever opposed to my
friend, Rush, whom I greatly loved, but
who has done much harm, in the sincerest
persuasion that he was preserving life and
happiness to all around him."

Jefferson was a bookworm from child-
hood. Naturally curious about how the
body is built, he purchased Cheselden's
classic book on osteology in 1764. Although
he opposed the theorizing to which doctors
were addicted, as well as bloodletting, he
did advocate knowledge of basic medical
sciences and of the history of medicine for
all educated men and recommended the
study of medicine to prospective students
of law. Francis Bacon and John Locke,
whose philosophy he carefully studied, the
latter a particularly favorite author, had
strong inclinations toward medicine and
exerted decided influences upon medical
philosophy. As a plantation owner, Jef-
ferson also realized that the health of the
slaves was economically important. While
he employed physicians to care for them,
he was always concerned about the
medical treatment they received. He wanted
to know what the doctor was giving him for
his family and why. When he was suf-
fering from urinary tract obstruction and
recurrent diarrhea in the evening of his
life, that part of his copy of Thomas'
Practice of Medicine dealing with these
subjects showed evidence of great wear.
Many of his medical friends presented him
with copies of their works. Wistar's Anat-
omy was in his library; so were Hosack's
Essays and his Practical System of Nosol-
ogy, as well as Ewell's Medical Companion
and his Improvements of the Science of
Medicine. The American medical journals
began to appear just before the turn of the
century and these, too, were in his library.

Pierre Cabanis

When he learned that his friend in
France, Pierre Jean George Cabanis (1757-
1808), planned a work on the reformation
of medicine, he expressed his approbation,
saying, "It needs the hand of a reformer
and cannot be in better hands than his."
This book appeared in 1804 and contained
a history of medicine with attacks on the
successive systems, theories, hypotheses
and the like, suggesting research and logic,
rather than abuse of the doctors by ridicule
and satire, in order to improve medical
practice.

Cabanis taught the history of medicine
in Paris and was a foreign member of the
American Philosophical Society. He lived
at the home of Madame Helvetius, the
gathering place for savants that included
the Abbe de la Roche, Turgot, Benjamin
Franklin as well as Thomas Jefferson, and
undoubtedly molded some of Jefferson's
views on medicine. Jefferson, in a letter
to Thomas Cooper (July 10, 1812), dis-
cussing psychology and related topics, ex-
pressed his admiration for Cabanis, when
he wrote: "A course of Anatomy lays the
best foundation for understanding these
subjects . . . and a mature study of the most
profound of all human compositions,
Cabanis' Rapports du Physique et du Moral
de I'homme. This was a book which first
appeared in 1802.

Cabanis published a book on the Degree
of Certainty in Medicine in 1797 which
was republished in 1802. In New York,
it was abstracted in English by Dr. Edward
Miller and more carefully translated later
by Dr. Rene La Roche in Philadelphia.
The works of Cabanis, so highly praised
by Jefferson, and the changes in medical
philosophy developing in France during
the first half of the nineteenth century
helped to moderate medical practice in this
country. Jacob Bigelow, a private pupil
of Benjamin Smith Barton, who was the
friend of Jefferson, in his writings exerted

THOMAS JEFFERSON AND THE DOCTORS

109

a marked impact on the medical profes-
sion of this country by adapting the
views of Cabanis to the American scene.
Appearing first in 1885, his essay on
"Self-limited Disease" was incorporated in
1851 into a book entitled Nature in Disease
which he dedicated to Robley Dunglison
as a token of his satisfaction in knowing
that Dunglison concurred with him in
these principles. In like manner, Elisha
Bartlett (dubbed "The Rhode Island
Philosopher" by William Osier) published
An Inquiry into the Degree of Certainty
in Medicine and into the Nature and Ex-
tent of its Power over Disease (1848) in
which he said he took up the subject
where Cabanis left off. The image of the
doctor in Bartlett's opening statement 120
years ago is as apt now as it was in the
time of the Roman satires of Martial. "I
am stating only what everybody knows
to be true," he wrote, "when I say the
general confidence which has heretofore
existed in the science and art of medicine
... has within the last few years been
violently shaken and disturbed, and is now
greatly lessened and impaired. The hold
which medicine has so long had upon the
popular mind is loosened; there is wide-
spread skepticism as to its power of curing
diseases, and men are to be found every-
where who deny its pretensions as a sci-
ence, and reject the benefits and blessings
which it proffers them as an art." Did he
have Jefferson in mind when he wrote
this?

Government and Medicine

Jefferson's passion for medical knowl-
edge went so far as to induce him, when he
drew up a projected body of laws for the
Commonwealth of Virginia in 1778, to
recommend that bodies of those hanged
for murder be delivered to anatomists for
dissection.

He was opposed to government meddling
I in medical practice, believing that the
powers of government should extend only

to such acts as are injurious to others.
The history of government fallibility in
medicine and science did not encourage
him to support the kind of centralized
supervision we have today. "Reason and
free inquiry are the only effectual agents
against error," he said in 1802, while he
was still in the White House. "Was the
government to prescribe to us our medi-
cine and diet, our bodies would be in
such keeping as our souls are now. Thus
in France the emetic was once forbidden as
a medicine, and the potato as an article of
food. Government is just as infallible,
too, when it fixes systems in physics. Gal-
lileo was sent to the Inquisition for affirm-
ing that the earth was a sphere; the Gov-
ernment had declared it to be as flat as a
trencher, and Gallileo was obliged to
abjure his error. ... It is error alone
which needs the support of Government.
Truth can stand by itself." Thus he
wished to separate science and Government
as he did Church and State.

Personal Medical Experiences

Jefferson's skepticism toward doctors
and medical practice must have been
aroused by the shocks of many unfortunate
medical experiences. His father died when
he was still at a very impressionable age.
Whatever the anguish and resentment of
the young adolescent at this time, however,
it was certainly not directed at the attend-
ing physician, Dr. Thomas Walker, who
was a friend of the family, a highly re-
spected citizen in Albemarle, related to
George Washington, and after the death
of the elder Jefferson, legal guardian to
Thomas Jefferson until he became of age
in 1764.

In the autumn of 1765, Thomas Jef-
ferson suffered another severe emotional
shock in the death of his favorite sister,
Jane, who was three years older than he.
Jefferson grieved for her all the rest of his
life. "Longe, Longeque Valeto," he wrote
in her epitaph. She had mothered him

110

SAMUEL X RADBILL

and was a close companion of his youth,
for he had been deprived of maternal af-
fection.

In 1773 Dabney Carr died at Charlottes-
ville at the age of thirty from a bilious
fever. He had been one of Jefferson's
most intimate friends, his bosom com-
panion in their studies and had married
a sister of Thomas Jefferson. The two
friends now lie in graves not two yards
apart.

Carr's death caused a serious mental
disturbance in his wife, Jefferson's sister
Martha, herself ill from a recent confine-
ment. Six fatherless children, along with
Jefferson's widowed sister, were taken into
Jefferson's home and raised as his own. The
death of one of them, Peter, a favorite of
Jefferson's, not long after was another blow
to Jefferson.

But his greatest grief came in 1782 when
his wife died. He was desolate. Taking
turns with his sister and his sister-in-law,
he had nursed her tenderly and for four
months was never out of calling distance.
Of the six children born to them, only
the eldest, Martha, survived to adulthood.

It is small wonder that he had little
faith in the help the doctors could render
and stated that the fatal errors of medical
theories are recorded in the necrology of
man. Years later he wrote philosophically
to John Adams about grief: "I have often
wondered for what good end the sensations
of grief could be intended. All our other
passions, within proper bounds, have a
useful object. And the perfection of the
moral character ... is a just equilibrium
of all the passions. I wish the pathologists
then would tell us what is the use of grief
in the economy, and of what good it is the
cause, remote or proximate."

I do not know who treated Mrs. Jef-
ferson in her last illness. Mr. Bear's Medi-
cal Chronology mentions many doctors,
from which I would assume that many
were tried and found wanting. The ac-
count books of Dr. George Gilmer record

visits to Mrs. Thomas Jefferson for sev-
eral years after the Jeffersons were mar-
ried. George Gilmer, Jr., a year older
than Jefferson, was the son of a physician-
apothecary of Williamsburg, nephew of
Dr. Thomas Walker and classmate of
Thomas Jefferson. After studying under
his uncle, Gilmer completed his medical
education in Edinburgh and eventually
set up in practice in Albemarle. He mar-
ried his cousin, Dr. Walker's daughter,
who was as much a patriot as her husband
and it is said she offered Mr. Jefferson her
jewels to use in her country's cause.

Jefferson and Small Pox
Prevention

A practical man, Thomas Jefferson was
unable to tolerate obscure speculations,
but the value of inoculation to prevent
small-pox was real to him. In 1766, when
he was twenty-three, he took the tedious
journey to Philadelphia to be inoculated
by Dr. William Shippen. He had been
referred to Dr. John Morgan by his friend,
George Gilmer, who had been a fellow
student of Morgan's in Edinburgh, but
Morgan just the year before had assumed
the professorship of medicine in the
newly opened Medical School at Phila-
delphia, and since he limited himself to
the practice of medicine probably referred
Jefferson to Shippen for inoculation since
it was a surgical procedure. When Jef-
ferson called on Morgan he was in-
structed and entertained by Morgan's col-
lection of Italian art and by his European
reminiscences. One student of Jefferson's
life believes Jefferson owed to John Mor-
gan "his real initiation into the arts." The
doctor's instruction and example were as
fruitful for the young Virginian's growth
in that field as were Small's in Science,
Wythe's in law and Fauquier's in music
and the refinements of worldly society.
Morgan also owned a collection of na-
tural curiosities among which were skele-
tal parts of a mastodon found at Big Bone

THOMAS JEFFERSON AND THE DOCTORS

Lick, Ohio, in 1766. These inspired Jef-
ferson's curiosity, leading him into a long
chase after the paleontological mysteries
of the "mammoth."

When Jefferson was in Philadelphia
again in 1775 his slave, Bob, was also
inoculated by Dr. Shippen; and the first
thing Jefferson did when he had re-
covered sufficiently from his grief after his
wife's death in 1782 was to carry oil his
own three children together with those of
his sister to an unoccupied house at Ampt-
hill to be inoculated. He remained with
them, acted as chief nurse, defending them,
I suspect, from the meddlesome medical
care so often insisted upon before and
after inoculation by the doctors. It was a
serious operation. Not only could it turn
out fatally, but it was necessary to isolate
the patients in order to prevent the spread
of the small pox.

When Jefferson in 1800 learned about
Edward Jenner's success with the much
milder cow pox vaccination, he immedi-
ately gave support to its dissemination in
this country.

Benjamin Waterhouse

The story of how the President and Dr.
Benjamin W ? aterhouse established vaccina-
tion in the United States has already
been told, but I would like to say some-
thing about Dr. Waterhouse. It was natural
for Waterhouse, a citizen of Massachusetts,
first to try to enlist the aid of John Adams
to encourage the use of vaccination, but
from Adams he received only verbal en-
couragement. At this time Jefferson was
anathema to Adams, and to industrial New
England in general and Harvard University
in particular. When Waterhouse of Harvard
turned to Jefferson he knowingly incurred
the hostile reaction of his own community.
Years later John Adams mellowed and
wrote to Benjamin Rush in 1812: "I am glad
Waterhouse has a son with you. The father
commands one of the most elegant and
masterly pens in America. He is a jewel of

a man and has been most cruelly used be-
cause he is a friend of the National Govern-
ment and because he writes better books
than any of his profession here."

Jefferson derived great personal gratifi-
cation from the results of the successful
dissemination of vaccine throughout the
United States. In 1801 Dr. John Redman
Coxe was able to introduce vaccination in
Philadelphia by successfully vaccinating
himself and his fourteen-day-old son with
vaccine virus sent to him by Jefferson,
thus propagating live vaccine matter for
subsequent use. At Jefferson's request, Coxe
sent him live small pox matter from one
of his small pox patients which Jefferson
then used to challenge the immunity of a
previously vaccinated subject. Jefferson
ever after retained an affection for the
oft maligned and badgered Waterhouse,
continuing a correspondence with him. In
1808, before leaving office as President, he
wrote happily to Benjamin Rush that he
had appointed Waterhouse to the Marine
Hospital Service in accord with the wish
of Dr. Rush. This appointment stirred up
some adverse criticism because Water-
house was such a controversial figure. In
this respect John Adams once observed to
Waterhouse: "I know not two characters
more alike than Rush's and yours." Writ-
ing to Adams in 1821, Waterhouse said:
"President Jefferson gave me a medical
appointment with $1500 per annum
avowedly for my successful labours in vac-
cination. When Dr. Eustis and some of
the doctors of the Army expressed their
dissatisfaction at it, Mr. Jefferson replied:
'During our Revolutionary War, we lost
in Canada, and on our frontiers, ten
thousand men by small pox; and we should
probably lose that number or more should
we have another war, had not Dr. Water-
house prevented such a calamity by ex-
pediting by his incessant labors, the prac-
tice of vaccination full twenty years sooner
than it otherwise would have been
adopted. Besides, I consider not merely

112

SAMUEL X RADBILI.

the Army, but the whole people of the
United States under obligation to him for
saving an immense number of lives.' "

In 1824 Waterhouse sent to Jefferson a
broadside listing the "heads of a course
of lectures on natural hist ory given an-
nually since 1788 in the University of
Cambridge;" and on May 31, 1825, he
paid his respects to the Father of the
University of Virginia at Monticello and
visited the newly opened University.

Benjamin Rush

Benjamin Rush was two years younger
than Thomas Jefferson. He taught at the
Medical School of the University of
Pennsylvania from the time of his return
from Edinburgh in 1769 until his death
from pneumonia. Active in practice, he saw
as many as a hundred patients in one
day during the yellow fever epidemic of
1793 and was able to write that day that
not one of them died. An inveterate writer,
in addition to his lectures and his medical
inquiries and observations, he covered such
diverse topics as slavery, alcoholic drinks,
Indians, duelling, capital punishment, and
so on. His account of the maple sugar in-
dustry was the first publication on the
subject. In his commonplace book under
date of May 13, 1791, he wrote: "Break-
fasted this morning with Mr. Jefferson and
read to him and Mr. Drinker an account
of the maple tree and sugar, etc. and
received some useful hints from each of
them on the subject." The account was
published in The Transactions of the
American Philosophical Society in 1791
in the form of a letter to Jefferson whose
efforts to grow sugar maples at Monticello
had proved unsuccessful. Rush praised
sugar not only for its dietary usefulness
but as a medicine in fevers, disorders of the
heart and other parts of the body, and
mentioned Franklin's penchant for black-
berry jam (presumably sweetened with
sugar) to relieve the effects of the stone;
he rejected the opinion that sugar injures
the teeth. He observed in his paper that

"Mr. Jefferson uses no other sugar in his
family than that which is obtained from
the sugar maple tree." Perhaps this was
good politics on behalf of his friend whose
political strength needed bolstering in New
England where the maple sugar came from.

Though Rush was often wrong, he was
never undecided, for which his students
as well as his patients adored him. Pa-
tients and students expect the doctor to
know, not "to think." Though Jefferson
disagreed with Rush on medical theories,
bleeding, purging and other medical mat-
ters, the two were in much agreement
otherwise. They had first met in Phila-
delphia on June 18, 1775 at a dinner given
to George Washington a few days after
Washington was appointed Commander-in-
Chief of the American Armies.

Rush characterized Jefferson as not less
distinguished for his political than his
mathematical and philosophical knowl-
edge and wrote that "the whole of Mr.
Jefferson's conversation on all subjects is
instructive. He is wise without formality
and maintains a consequence without
pomp of distance." During the decade that
Philadelphia was the capital of the Na-
tion, they were frequently brought to-
gether especially at the American Philo-
sophical Society where they were both
members. A loyal follower of Jefferson in
politics, Rush's heartfelt letter of congratu-
lations on his friend becoming Presi-
dent of the United States was one of the
finest Jefferson received. Rush's solicitude
upon learning of Jefferson's illness, one
time, touched the latter so that he gratified
Rush with an account of his symptoms
and was rewarded with an extended letter
of medical advice drawn exclusively from
empirical observation in deference to Jef-
ferson's distrust of medical theories. After
Rush died, Jefferson returned Rush's let-
ters to his family, but this one he kept,
saying he might want to refer to it again
when he needed it.

When Rush presented a copy of his Six
Introductory Lectures to Jefferson in 1801,

THOMAS JEFFERSON AND THE DOCTORS

113

he informed Jefferson that "vaccination,
as you have happily called it, has taken
root in our City and will shortly super-
sede the old mode of inoculation." A year
later he mentioned his investigations into
the causes, seats and remedies of madness
and other diseases of the mind, requesting
the loan for a week or ten days of a copy
of Latude's Memoirs from Jefferson's li-
brary because it contained an account of
the author's confinement in the Bicetre
hospital for lunatics in Paris where Pinel
had first cut the chains from mad patients.
When the Lewis and Clarke expedition
was preparing to set out on its explora-
tory mission, Jefferson sent Lewis to Phila-
delphia where Rush, at Jefferson's request,
prepared medical questions for the ex-
pedition, as well as medical advice for
the members of the expedition. This copy
of medical directions is now in the Library
of Congress.

In 1805, Rush applied for the post of
director of the mint but Jefferson had to
inform him he had already appointed
Robert Patterson, citing the need for
special talents in this post and explaining
to Rush that decisions of this sort "are the
most painful part of my duty. ... I must
anatomize the living man as the Surgeon
does his dead subject, view him as a ma-
chine and employ him for what he is fit
for, unblinded by the mist of friendship."
Rush suggested to President Jefferson
that he consider the problems of Yellow
Fever and quarantine laws in a Message
to Congress which Jefferson did in his
Fifth Annual Message of December 3rd,
1805, recommending an inquiry into the
state quarantine laws.

Rush devised a tranquilizing chair for
the treatment of lunatics and one of the
last of his publications to appear during
his lifetime was his classic on Diseases of
the Mind which won for him the title of
Father of American Psychiatry.

One of the most satisfying achievements
for Dr. Rush in his last years was the
reconciliation he brought about between

Jefferson and Adams. Adams gave vent to
his joy at this reconciliation by calling
Rush "Mr. Conjurer," saying, "the mighty
defunct potentates of Mount Wollaston
and Monticello by your sorceries and
necromancies, are again in being."

When Rush died in 1813, he was
mourned by both Adams and Jefferson.
From Monticello Jefferson wrote to Adams:
"Another of our friends of seventy-six is
gone, another of the co-signers of the in-
dependence of our country; and a better
man than Rush could not have left us,
more benevolent, more learned, of finer
genius, or more honest."

The Medical Signers of the
Declaration of
Independence

That Rush was a signer of the Declara-
tion of Independence, a document so dear
to the heart of Thomas Jefferson, is
known to everybody; and nearly every-
body knows that there were other medical
signers. But hardly anyone knows who they
were. All were medical or political ac-
quaintances of Jefferson. Josiah Bartlett
was the first to approve the Declaration.
Chief Justice of New Hampshire and
Governor, he was the founder and first
president of the New Hampshire Medical
Society.

Matthew Thornton was another signer
from New Hampshire. He practiced medi-
cine at Londonderry, was surgeon of the
New Hampshire troops in the Louisville
expedition of 1745 and, being absent at the
time of the signing on August 19, 1776,
has the distinction of being the last to
affix his signature.

Lyman Hall, first trained in the minis-
try, turned to medicine and was a promi-
nent practitioner of Georgia when he
went to Philadelphia with Button Gwin-
nett and signed the Declaration. He, too,
was Governor of his State.

George Taylor, a signer from Pennsyl-
vania, was an Irish Protestant who stud-
ied medicine under the duress of his

114

SAMUEL X RADBILL

family's desires but ran away from home
and came to Philadelphia as a redemp-
tioner, married the boss' widow and rose
to fame and fortune in the iron business.

Oliver Wolcott, who, like his father
and his son, served as Governor of Con-
necticut, studied medicine with his brother
and practiced in Litchfield, but the pres-
sures of public duties forced him to give
up medical practice.

The American Philosophical
Society

Jefferson was elected President of the
American Philosophical Society, an organi-
zation which, like the Royal Society of
England, included medicine and anatomy
in its field of interest. Among its members
at least sixty-five were physicians, known
at least by name to Jefferson. Many of
them were absorbed in study of natural
philosophy, natural history, husbandry
and other matters that constantly agitated
the mind of Jefferson. His first contribu-
tion to the proceedings, in 1779, con-
cerned health springs, known as the
Sweet Springs which he mentioned in his
Notes on Virginia. He served on Com-
mittees with Benjamin Smith Barton,
James Hutchinson, Caspar Wistar, Benja-
min Rush and other doctors, and only
Benjamin Franklin and Dr. George B.
Wood served the Society for a longer term
of years as president.

ROBLEY DUNGLISON

Dr. Wilhelm Moll, in a list of Uni-
versity of Virginia "firsts," has pointed
out that Dunglison was the first full time
American Professor of Medicine in this
country. One of his courses, instigated by
Jefferson, was entitled "The History of
the Progress and Theories of Medicine,"
a title distinctly Jeffersonian and again
calling to mind Cabanis. Dr. William B.
Bean, a son of this Alma Mater, pointed

out in this auditorium that Mr. Jefferson's
influence on American medical education
affected Dunglison as it did the entire
medical profession of this country. Your
own Dr. C. L. Gemmill has also studied
the many facets of Dunglison's medical
work. Jefferson was 82 when Dunglison
first met him, but mentally clear and his
logic was irresistible. After Jefferson's
death, Dunglison went on to become one
of the foremost medical writers and edu-
cators of his time and exerted a decided
impact upon physicians and teachers
throughout the United States.

His farewell address when he left the
University of Virginia reflected much of the
influence of Jefferson upon him as he re-
called urging his students to avoid being
wedded to any exclusive sect or system, to
watch the march of nature and where in
doubt to give the patient the benefit of
the doubt rather than risk safety by rash
treatment. One of the first tasks under-
taken by Jefferson after the medical school
began to function was to assemble for
Dunglison's teaching a collection of ana-
tomical preparations. These are listed in
Dr. John M. Dorsey's book, The Jefferson-
Dunglison Letters.

Jefferson chose Dunglison for his per-
sonal physician, saying, "Time and ex-
perience are needed to make a skilful
physician, and nature is preferable to an
unskilful one. I had therefore made up
my mind to trust to her altogether, until
your arrival gave me better prospects." The
University Board of Visitors then promptly
passed a resolution on March 5, 1825, per-
mitting "the Professor of Medicine to
practice physik within the precincts of
the University." Seven months later they
broadened this to permit consultation
practice. In the words of Gemmill and
Jones, Dunglison, at the University of
Virginia, was teacher, savant, scholar and
physician.

Felix d'Herelle and Bacteriophage Therapy 1

By S I | l J. I

ACCOMPANIED by journeyman ral
L\ killci Gustal Sondelius and armed
with crates ol bacteriophage am-
pules, Martin ^rrowsmith, Sinclaii Lewis'
charming young avatai ol scientific ideal-
ism, lands on fictitious St. Huberl n< >i
merely t<> fighl the plague on the island,
hul to test object ivch tlie therapeutit ef-
ficacy i>l his cherished phage: "llall to gel
tlie phage, hall l<> be sternly deprived." II
his treatmenl is successful under controlled
conditions, reasons Arrowsmith, his con-
tribution is noi onl) ephemerally hu-
mane, bul also permanently valid as
Science, and thus in the long run gen-
uinel) humanistic. Bul a tropical country
in the grip ol disease he finds to be dis-
tinctly disorganized and "unstatistical;"
his decisive experiment is not lnll\
achieved — he will contribute to the sci-
entific literature another "suggestive" but
ambiguous report on "bacteriophage ther-
apy."

Io Felix d'Herelle (Figure 1), the Ca-
nadian-born (1873) co-discoverer of the bac-
i teriophage, the curative and prophylactic
abilities of his finding were never ambigu-
ous 01 doubtful, but certain and powerful.
His belief in the ( ausal relationship between
the bacteriophage and recovery from dis-
ease was not merely a beneficially applicable
afterthought to the discovery, but as we
will sec. an inseparable component of his
new concept ol infectious disease and re-
covery.

The system which he formulated had its

1 Edward Bell Krumbhaar Prize Essay VIII, Sec-
tion on Medical History. I lie College of Physicians
of Philadelphia, 1968.

2 Class of 1971, Temple University School of Medi-
cine, Philadelphia, Pennsylvania 19140.

EITZM.W, h a.'-'

beginning with an observation nude on .1
sample ol stool noi Erom .1 dysentery pa-
tient, but, significantly, from .1 convales-
( oil ol 1 his hac ill. 11 \ disease ( 1 ).

One day in the course of these experiments (2),
having mixed .1 quantity ol filtrati obtained origi

nail) 1 1 the st< >< il ol .1 dysi 1 1 1 1 n convaleso nt , with

.1 culture ol dysentery bacilli, I placed them in the
inc u ha I or hoping thus lo ohtain a soi 1 of "ripening,"

.1 more intimate association hetween the two
organisms. What \\;is my astonishment on the fol-
lowing da) 1 h nil the culture media pel Ic e 1 1\ c lear.

Iii Inline years, as d'Herelle isolated and
investigated bacteriophages ol othei path-
ogenic bacteria, he would always observe
dial he did so only from patients recover-
ing, and nevei Erom those dying; other
workers would not agree.

Following the initial reporl (3) which
d'Herelle published in the 1!M7 Comptes
Rendus Acadimie des Sciences, he and
colleagues at the Institut Pasteur in Paris
pursued the study of experiineni.il and
therapeutic aspects of "Bacteriophagum
intestinale," as he termed it, alter be-
coming convinced the lytic agent was a
living parasite of bacteria (4). Apparently
the earliest direct tests of the curative
powers of dysentery bacteriophage were
made by d'Herelle and M. Nadal at the
Hdpital des Enfants Malades: five chil-
dren were treated orally with a bacterio-
phage suspension tested Eoi virulence on
the "Bacillus dysenteriae Shiga" (i.e., now
Shigella dysenteriae) isolated from the
patients' sterols. Strikingly, all the young-
sters recovered and were discharged from
the hospital!

Outside of d'Herelle's group in Paris,
there was little interest in "Bacterio-
phagum intestinale" until d'Herelle in
l!)-!l issued his fust ol several monographic
summaries (5) of his research, both "basic "

1 11.

STEVKN J. I'l l I / \l \ \

I n. I. Iclix d'Hcic-llc (I87.V10CI).

.md "applied." Le Bacteriophage: Son
role dans Vimmunite and its English trans-
lation w hit h soon appeared contained the
basi< elements ol d'Herelle's developing
s\suin ol infectious disease and recovery,
and — likel) more stimulating to the medi-
cal community— the reports ol the remark-
able success enjoyed in the treatment ol
bacillar) dysentery. In the next loin years,
no less than six hunched papers concerning
one 01 .mother aspect ol the bacteriophage
phenomenom occupied (he pages ol medi-
cal journals from all parts of the world, a
<ioodl\ number in those earlv clays of the
"literature explosion." Jose da Costa Cru/
at the Instituto Oswaldo Cruz in Rio de
Janeiro initiated trials of treatment of
dysentery with bacteriophage shortly after
reading d'Herelle's monograph, but could
obtain no therapeutic: effec t at fust. W ithin
two years, however, many apparent sue

cesses had made him a devoted, though
geographically distant disciple ol the Cana-
dian bacteriologist: "Here in Rio de
Janeiro," he reported in 1924, "the me thod
has been thoroughly tried out, and is today
the routine method ol treatment." Da
Costa Cru/ ((i) even noted thai in some
cases the "rapidity of the recover) has been
a cause ol aina/enienl ." On the- other
hand. Wilburl C. Davison, at the Depart-
meni ol Pediatrics ol Johns Hopkins,
issued a paper (7) in 1!)22 — displaying
somewhat deplorable vagaries ol dosage —
which reported no noticeable eflect ol the
phage in treating bacillar\ dysentery.

Other bacterial diseases were succes-
sively subjected to bacteriophage therapy
in the earl) I920's: lieckerich and Haude-
roy tieated t\phoid and E. coli infections
in France; liruynoghe and Maisin, and
Gratia staphylococcus lesions in Belgium;
Baz) in Fiance and M< Kinky in the
United States — wound infections (8).
D'Heielle himsell did some preliminar)
work with plague bacteriophage in Indo-
China in 1920 and in Egypl in 1925. These
names are mentioned foi die primac) ol
theil work: numerous physicians around
I he world followed them in the I92()'s and
later in treating disease with bacterio-
phage, accumulating a bod) ol the most
contradictory clinical literature conceiva-
ble. Every paper reporting exciting success
could be matched b) at least one noting
dismal lailure. Then in !')-!(> d'Herelle's
The Bacteriophage and lis Behavior ap-
peared, and this new and expanded sum-
mary, presenting most convincingh the
apparent evidence for the worth of the
novel therapy, further encouraged various
workers, who in turn contributed still
more confusing and conflicting findings.

The final major expansion of bacterio-
phage therapy was mainly begun by its
perfervid advocate; d'Herelle, whose in-
volvement with tropical medicine even
pre-dated his bacteriophage work, once
termed cholera his "favorite malady."

FELIX D'HERELLE AND BACTERIOPHAGE THERAPY

117

Finally, in 1928 d'Herelle, assisted by
Major Malone of the Indian Medical
Service and his staff, commenced a series of
experiments in the villages of the Punjab
(9). They first studied untreated patients
to verify that the appearance of virulent
anti-vibrio phage in the intestine corre-

1 spondee! with the occurrence of natural
recovery. Supported by the findings,
d'Herelle proceeded to treat cholera orally
with bacteriophage preparations, but his
theory of bacteriophage' pointed to even
more profound benefit: "To cure disease
once it has developed is not without in-
terest," he later wrote about the cholera
programs, "but to prevent the disease is
still more important." So into each of the
wells of Ghang, Nawar, and other villages
of the Punjab members of Major Malone's
staff poured "two ounces of virulent bac-
teriophage culture (10)." According to
d'Herelle, this invariably succeeded in
stopping incipient epidemics.

What was the "theory" or "system" of
infectious disease and recovery which
d'Herelle constructed upon the bacterio-
phage phenomenon? With the experiences

1 with cholera in India providing, in the
discoverer's mind, additional confirmatory
evidence, d'Herelle published in 1930 his

1 most definitive (though concise) statement
of his ideas: The Bacteriophage and its
Clinical Application (11). In it is summa-

' rized the author's concept of bacterio-
phage and disease.

Firstly, the bacteriophage (now "Proto-
bios bacteriophage") is a living, sub-cellu-
lar parasite of bacteria; as all higher forms
of life are parasitized, so is the micro-
scopic pathogen. Disease and recovery are
functions of the dynamic interactions of
three organisms: the bacteriophage, the
bacterium, and the infected animal host.
d'Herelle concludes (12):

In brief, when bacteria and bacteriophage are
brought together, one of three things will happen in
accordance with the conditions present. The bac-
teriophage may destroy the bacteria; the bacteria

may resist and destroy the bacteriophage; or, finally,
an equilibrium may become established between the
resistance of the bacteria and the virulence of the
bacteriophage. In this last case, both survive and
the bacteria contract a chronic disease, that is, a
symbiosis is established. Such a state of equilibrium
is, indeed, extremely frequent in nature.

These three possible outcomes correspond
in the host animal to recovery from dis-
ease, death, and chronic disease. Recovery
must be distinguished from immunity: the
mechanisms for immunity from disease,
whatever they may be, are in no way re-
sponsible for recovery once disease is mani-
fest. Without doubt, in bacillary dysentery,
cholera, plague, and presumably all bac-
terial diseases, bacteriophage is the means
of recovery; the sub-cellular "protobe"
must assume a "virulent" form which will
lead to both lysis of the bacteria and will
enhance phagocytosis (13). If the suffi-
ciently virulent form does not emerge, the
animal dies. Following recovery, the solu-
ble remnants of the lysed bacteria stimu-
late the immunity mechanisms.

An epidemic represents the adaptation
of a pathogen to a form resistant to the
phage, but eventually the tinier microbe
will in turn assume (mutate) a form viru-
lent to the bacteria and the epidemic ends.
Bacteriophage may be spread by means
identical to those capable of disseminating
pathogens; thus, an epidemic of disease is
followed by an epidemic of cure! Finally,
since bacteriophage is the mechanism of
recovery from infectious disease, "... ther-
apy with bacteriophage provides the spe-
cific therapy par excellence and, it might
be said, the only possible natural specific
therapy, for it is the exact experimental
reproduction of the natural process of re-
covery (14)."

Such was the role of the bacteriophage
in biology as viewed by its co-discoverer
in 1930, a year which saw continuing trial
of the new therapy. And by 1930 (and
probably some years earlier) another factor
was added to what was becoming an in-

118

STEVEN J. PEITZMAN

creasingly controversial story — commercial
exploitation.

While it is difficult to ascertain pre-
cisely when and which firms began pro-
ducing and promoting bacteriophage prod-
ucts, at least three major American drug
companies (15) included such preparations
in their catalogues in the early 1930's. E.
R. Squibb &: Sons recommended its
"Staphylococcus Bacteriophage Squibb Poly-
valent" for "staphylococcus infections,
particularly furuncles and carbuncles,"
claiming for it "an almost immediate ef-
fect in relieving pain." A twenty-cc. vial
was priced at $3.50. Lilly Research Labora-
tories advertised "Bacterial Antigens in a
Water-Soluble Jelly Base . . . for local ap-
plication in the treatment of certain in-
fections." "Staphylo-Jel," the catalogue as-
sured, produces "... a marked diminution
in the pain and soreness; the necrotic core
liquefies rapidly and comes out easily;
healing is prompt and scarring said to be
less." Lilly explains its peculiar choice of a
gel base in terms of convenience and effi-
ciency; it is possible that this novel prepa-
ration was also seen as more patentable
than a simple filtrate. Swan-Myers division
of Abbott Laboratories also marketed bac-
teriophage preparations for staphlococcus
and E. coli infections.

The Anglo-French Drug Company, an
international corporation, seems to have
been the major producer of bacteriophage
products in the early 1930's. Its "Labora-
toire de Bacteriophage" in Paris was
founded by d'Herelle, though an advertis-
ing pamphlet explains the nature of the
relationship (16). It reads:

Since no personal profit was sought by Professor
d'Herelle, and since it was desired that the Labora-
tory should retain a purely scientific character, Arti-
cle 13 of the statutes of the Act of Foundation of
the firm stipulates that the profits of the . . . [Bac-
teriophage] Laboratory . . . shall be devoted to sci-
entific research.

Contrasting with this admirable statement
is the undeniably mercantile plea several

pages later: "When Prescribing Bacterio-
phages Specify Bacteriophage (d'Herelle)
THE ORIGINAL BACTERIOPHAGE
Supplied in Boxes of 10 Ampoules of 2 cc."
Available from Anglo-French were "Bact£-
Dysenteri- Phage," "Bactd-Pyo- Phage,"
'Bactd-Coli-Phage," "Bacte-Intesti-Phage,"
"Bact£-Staphy-Phage," and "Bactd-Rhino-
Phage."

The proliferation of commercial bacte-
riophage medicines was in part responsible
for the first reliable evaluation of the
whole bacteriophage therapy picture — that
by the American Medical Association
Council on Pharmacy and Chemistry late
in 1934. Evidently the opposing voices of
the claimants for and condemners of the
heterodox new treatment had already
several years before this succeeded in ir-
ritating the ears of many sincere and
educated physicians. "There is a rapidly
growing resentment and distrust of the
whole bacteriophage promotion," wrote an
A.M.A. editorialist in 1933 (17), "which
certainly will delay final clinical evalua-
tion." The influential British journal
Lancet commented in 1932 that "the re-
sults obtained [from many trials of bacte-
riophage therapy] have been so contradic-
tory as to suggest to the unbiased and
non-technical observer that once again a
vaunted remedy is under-going the slow
and painful process of discredit (18). . . ."

This unhappiness with the developing
story of phage therapy suggests that the
1934 A.M.A. report was timely and wel-
comed. The Council on Pharmacy and
Chemistry, which had never "accepted"
any of the bacteriophage remedies, comis-
sioned two highly competent microbiolo-
gists, Monroe D. Eaton and Stanhope
Bayne-Jones, to review the literature and
evaluate the status of d'Herelle's treatment.
Based upon what appears to be very ade-
quate survey of the journal reports, the
conclusions they reached were far from
enthusiastic. The great majority of the
clinical articles, they suggested, both pro

FELIX d'HERELLE AND BACTERIOPI I.U.F. THERAPY

119

and con, are not reliable, invalidated by
poor controls or small series of cases. Only
in the treatment of focal staphylococcus
disease and possibly bladder infection is
the evidence at all convincing. Further-
more, experimental data from investiga-
tions using "artificial" disease in animals
indicate that the bacteriophage phenome-
non occurs only to a small extent or not at
all in vivo — body fluids are apparently
strongly inhibitory. Finally, proposed
Eaton and Bayne-Jones, "The favorable
results reported may have been due to the
specific immunizing action of the bacterial
proteins in the material used and to non-
specific effects of the broth (19)."

Though it is difficult to assess the in-
fluence of this report, it can at least be said
that the late 1930's saw the beginning of
the decline of bacteriophage therapy. At
the First International Congress for Micro-
biology in 1930, d'Herelle delivered a
typically forceful presentation of his the-
ory (20); he did not participate in the
larger Second Congress in 1936. Bacterio-
phage preparations remained in drug
firms' catalogues, but towards the 1940's
their antigenic rather than bacteriocidal
aspect was emphasized. And perhaps most
significantly, the number of journal re-
ports dealing with bacteriophage therapy
diminished substantially as 1940 ap-
proached.

In 1941, the A.M.A. Council on Phar-
macy and Chemistry judged that it was
time to re-evaluate bacteriophage therapy
and to bring up to date the literature sur-
vey of 1934. Albert P. Kreuger and E. Jane
Scribner were called upon to do this task
and, like their predecessors, appear to have
done a competent job. Their evaluation
was actually somewhat more favorable
than the earlier report, but they empha-
sized that there had still been no con-
vincing demonstrations to finally support
or discredit bacteriophage therapy.

While the medical community during
the 1930's and 40's began somewhat to lose

interest in his therapy, Felix d'Herelle, un-
ceasingly confident, pursued several new
and expansive projects. At the invitation
of the government of the Soviet Union he
left Yale University (where he had been
Professor of Protobiology some years) in
1934 to establish bacteriophage laborator-
ies in Xiflis, Kiev, and Kharkov (21). But
in 1936 one of the purges then prevalent
in Russia somehow resulted in the arrest
and execution of Eliava, d'Herelle's old
friend and colleague from the Institut
Pasteur years; the Canadian bacteriologist
returned to Paris. Here he prepared the
final in his series of periodic monographic
statements of his work and theories, Le
phenomene de la guerison dans les mal-
adies infectieuses, which was published in
1938. Though he continued his study of
bacteriophage in a small laboratory in
Paris, he published very little in the last
decade of his life, and he died in 1949.

Perhaps the last significant paper con-
cerned with bacteriophage therapy was a
third and final evaluative report in 1945
by the A.M.A. Council on Pharmacy and
Chemistry — but limited now to treatment
of bacillary dysentery (22). The conclu-
sions? The evidence for the effectiveness of
bacteriophage in the treatment of bacillary
dysentery — the ailment for which d'Herelle
had first attempted treatment more than
twenty-five years before — was as of 1945
still inconclusive though suggestive: more
careful studies should certainly be done!
They never were: sulfonamides and anti-
biotics served as the final forces in the
demise of bacteriophage therapy.

II

How is it possible that after nearly
thirty years of clinical trial, much of it re-
ported in the journal literature, the worth
of bacteriophage as therapy was neither
convincingly established nor disproved?
While it may be simply argued that the
history of medicine demonstrates the
reluctance with which valueless remedies

STEVEN J. PEITZMAN

120

die (bloodletting, Homeopathy), the am-
biguous verdict for bacteriophage therapy
may be more specifically attributed to the
peculiar nature of the diseases upon
which it was tried, the geographical dis-
tribution of these diseases, and to the im-
perfect dissemination of the "scientific
method" in the period between the two
World Wars.

If it be recalled that the diseases treated
with bacteriophage were mainly bacillary
dysentery, cholera, and focal staphylococ-
cus lesions, some of the problems in eval-
uating the treatment may be imagined.
Bacillary dysentery and staphylococcus
abscesses are mainly self-limiting diseases
of low mortality; thus, even a truly valid
remedy would not be expected to yield
spectacular, persuasively dramatic effects.
Dysentery presents certain diagnostic prob-
lems "in the field," another potential
source of confusion. Cholera is perhaps
more readily diagnosed and can certainly
be lethal if not properly treated, but like
dysentery and plague occurs in large num-
bers in tropical areas not conducive to the
most careful, impartial studies (23) — as
Martin Arrowsmith harshly learned!

With these difficulties sympathetically
appreciated, the failings of the bacterio-
phage therapists as scientists may be con-
sidered. As the comtemporary evaluations
pointed out, most of the reports — pro and
con — show small numbers of studied cases
and poor or no controls. Often faulty
supervision of treatment and other errors
invalidated the findings. To illustrate, we
can select several papers which are by no
means among the worst offenders. Morison
and Vardon (24) published "A Cholera and
Dysentery Bacteriophage" in the 1929 In-
dian Journal of Medical Research. These
workers discussed twenty-seven cases of
cholera; of twenty-one not receiving phage,
sixteen died, but of the six given phage,
only one died — suggestive, yet the numbers
are too few. "The first case in which we

had an opportunity to test the bacterio-
phage," writes Morison,

was admitted to the Military Hospital under Captain
Roscnbloom, I. M.S., with severe vomitting, large fre-
quent rice-water stools, cramps and collapse. He was
given intravenous hypertonic saline to which 2 cc.
of bacteriophage was added and received 2 cc. of
bacteriophage in water by the mouth every four
hours. Within 18 hours he had recovered and ap-
peared so well that a diagnosis of cholera was
doubted. Cholera vibrios, strain J., were recovered
from his stool on the first day of the illness.

This clinician has given the bacteriophage
by two different routes, in conjunction
with other treatment (intravenous saline),
and then it is not entirely certain that the
case was cholera!

Also in 1929, Compton reported his
success with bacteriophage therapy in
sixty-six cases of bacillary dysentery in
Alexandria, Egypt (25). He distributed the
phage with a "circular instructing the
patient on the use of the phage" and a
"questionnaire to the doctor" (local prac-
titioners were intermediates). The sixty-six
cases turn out to represent those coopera-
tive sufferers who bothered to return the
form out of a total of two-hundred treated
patients. Compton assumed all the others
were cured, since if the disease had per-
sisted, they would have returned to their
doctor! In fairness to Morison, Compton,
and by implication many others, it must
be emphasized that those physicians re-
porting no success were about equally
guilty of these methodological "errors."

If this seeming ignorance of the prac-
tices of the "scientific method" appears
inconsistent with twentieth century medi-
cine, the contradiction is partially re-
solved by merely accepting the fact of
gradualness. In very general terms, the
basis for modern quantitative and objec-
tive medical study was provided in the
nineteenth century laboratories of such
men as Bernard, Ludwig, and Loeb; the
extension of their methods and ideals
from the realm of "basic sciences" into

FELIX D'HERELLE AND BACTERIOPHAGE THERAPY

121

clinical medicine and therapeutics has
been the slow and still incomplete task of
the present century. Often this extension
depends on nothing more or less than the
individual physician, in school or if need
he later, learning the necessary conven-
tions and the use of statistics — just as
Martin Arrowsmith had to acquire calcu-
lus and physical chemistry to satisfy his
teacher, Max Gottlieb. Unhappily, the
practitioners who applied bacteriophage
therapy and reported their results in the
1920 s and 1930's were on the whole in-
completely educated in the needed "new"
practices. Though probably neither un-
aware of nor hostile to the ideas of con-
trols and quantitative expression, they did
not know how to apply them: as a result,
their conclusions were too often meaning-
less. And in fact it must be said that the
spectacular cures of the bacteriophage
therapists were classic "artifacts" — illu-
sions of their own unaware creation (26).

Felix-Hubert d'Herelle, the most zealous
and unyielding advocate of his own ther-
apy, emerges as a paradoxical figure.
Though seen by his colleagues as a me-
thodical, disciplined bacteriologist, he was
guilty, not so much of performing invalid
studies, but of accepting those of others
perhaps a little too indiscriminately.
' Furthermore, the reader of his periodic
monographs — summary statements of his
work and theory — is struck by an unfailing
didacticism and oppressive singleminded-
ness. Fairly typical is his estimation of his
impact of bacteriophagy in the preface
(27) to the 1930 version:

As the last century closed — that period of blissful
satisfaction — the biologists also had erected a
splendid structure into the foundations of which
they had harmoniously interlocked the cellular
theory of life, the theory of the fixity of bacterial
species and that of the "antibodies" ornamented
with "side-chains" such as would explain recovery
and all immunity. Suddenly bacteriophagy made its
i I appearance. The structure could not support die
added weight of the new facts: it crumbled. The

cellular theory of life is manifestly false, for life
is an attribute of intracellular particles. The anti-
bodies play no part in the phenomena of recovery.
The form and the properties of bacteria are in-
herently variable characters.

Frankly, d'Herelle seems now almost
more a throwback to the nineteenth cen-
tury — the "period of blissful satisfaction,"
as he termed it — than a member of the
scientifically sophisticated twentieth cen-
tury — the period of the cautiously quali-
fied claim. Both his bold and unequivocal
assurances of cure and his heroic develop-
ment of an entire revolutionary system
upon one series of observations seem oddly
foreign to modern medical procedure.
Coming as it did while Ehrlich and his
followers were gradually building the
science of immunology, d'Herelle's pro-
posal of a heterodox, completely-contained
bacteriophagic theory of disease and re-
covery was almost atavistic. Perhaps
Felix d'Herelle, like those practitioners
who tested his therapy, was a kind of
transition figure. Not quite twentieth cen-
tury, he had learned the methods and con-
ventions of the new century's science, but
retained from an earlier era of medicine an
uninhibited sense of personal assertion.

NOTES AND REFERENCES

1. d'Herelle, Felix: The Bacteriophage and Its

Clinical Applications. Charles C Thomas,
Springfield, Illinois, 1930. (Translated by
George H. Smith.)

2. Like many other bacteriologists, d'Herelle had
noted occasional spontaneous lysis in broths and
had bqgun a systematic search for the phenome-
non early in his career. This was interrupted by
World War I, which saw d'Herelle and other
microbiologists preparing sera, etc. Frederick
William Twort reported the bacteriophage phe-
nomenon in 1915, though d'Herelle later insisted
his discovery and Twort's were not the same
thing.

3. d'Herelle, F.: Sur un microbe invisible antago-

niste des bacilles dysenteriques. Comptes
Rendus Acad. Sci. 165: 373, 1917.

4. d'Herelle later assigned the name "Protobios
bacteriophagus" when the phenomenon was seen
to extend beyond only enteric bacteria. Years

122

STEVEN J. PEITZMAN

later, the drug firms were unjustifiably accused
of coining the term "bacteriophage" in order to
convey the idea of a bacteriocidal action.

5. d'Herelle, F.: Le Bacteriophage. Son rdle dans

Vimmuniti. Masson, Paris, 1921.

d'Herelle, F.: The Bacteriophage: Its R6le in
Immunity. Williams and Wilkins, Baltimore,
1922. (Translated by George H. Smith.)

Later versions:

d'Herelle, F.: The Bacteriophage and Its Be-
havior. Williams and Wilkins, Baltimore, 1926.
(Translated by George H. Smith from the
French version, Le bacteriophage et son com-
portment, 1926.)

d'Herelle, F.: The Bacteriophage and Its Clini-
cal Applications. Springfield, Illinois, 1930.
(Translated by George H. Smith, but appar-
ently never published in original French.
"Each of the chapters of the text corresponds
to one of the Lane Lectures, delivered at
Stanford University, in October of 1928." — p.
vii.)

d'Herelle, F.: Le phdnomene de la gucrison dans
les maladies infectieuses. Masson, Paris, 1938.

6. da Costa Cruz, J.: Le traitement des dysenteries

bacillaires par le bacteriophage. Comptcs.
Rendus. Soc. Biol. 91: 845, 1924. (Quoted and
translated in d'Herelle, 1926, English edition.)

7. Davison, W. C: The bacteriolysant therapy of

bacillary dysentery in children. Am. J. Dis.
Children 23: 531, 1922.

8. See d'Herelle, 1926, English edition, chapter 6.

9. This extensive work was fully reported in a large
monograph:

d'Herelle, F., Malone, R. H., and Lahiri, M.
X.: Studies on Asiatic Cholera. Indian Medical
Research Memoirs, no. 14, 1930.

10. See d'Herelle, 1930, chapter 5.

11. Note 5.

12. d'Herelle, 1930, p. 237.

13. It was fairly widely believed that bacteriophage
in the blood had an opsonic effect.

14. d'Herelle, 1930, p. 242.

15. The following sources provided information
about the commercial bacteriophages:

Straub, Marcaret E., and Applebaum, Martha:
Studies on commercial bacteriophage products.
J.A.M.A. 100: 110, 1933.

E. R. Squibb & Sons: Physician's Reference Book
of Squibb Biological Products and Pharma-
ceutical Specialties. New Brunswick, N.J., 1935
and 1941.

Lilly Research Laboratories: Distinctive Prod-
ucts. Indianapolis, 1932.

Eli Lilly 8c Co.: De re medicina. Indianapolis,
1938, 1941, 1951. (This is just a catalogue of
products.)

Anglo-French Drug Co.: Therapeutic Uses of

Bacteriophage (d'Herelle). [New York, 1932?]
(An undated advertising pamphlet, probably
1932.)

16. Note 15.

17. Commercial Aspects of Bacteriophage Therapy.

(editorial). J.A.M.A. 100: 1603, 1933. (Other
interesting J.A.M.A. editorials, both titled,
"Limitations of Bacteriophage Therapy," may
be found in J.A.M.A. 96: 693, 1931, and 98:
1190, 1932.)

18. [Editorial comment] Lancet 2: 198, 1932.

19. Eaton, M. D., and Bavne-Jones, S.: Bacterio-

phage Therapy. Special Report of the Council
on Pharmacy and Chemistry. J.A.M.A. 103:
1769-76, 1847-53, 1934-9; 1934.

The later A.M.A. Council on Pharmacy and

Chemistry reports discussed are:

Krelt.er, A. P., and Scribner, E. J.: Bacterio-
phage Therapy II. Bacteriophage: Its nature
and its therapeutic use. J.A.M.A. 116: 2160-7,
2269-7, 1941.

Morton, Harrv E., and Encley, Frank B.:
Dysentery Bacteriophage. Review of the litera-
ture on its prophylactic and therapeutic uses
in man and in experimental infections in ani-
mals. J.A.M.A. 127: 584, 1945.

20. E.g.: ". . . Failure et la gucrison des maladies in-
fectieuses chez l'individu isole-, aussi bien que la
marche et la cessation des epidemies, sont sous sa
dependance directe." (from I" Congres Interna-
tional de Microbiologic: Resumes de Rapports,
Conference et Demonstrations. Paris, 1930.)

21. The Russians continued experimenting with
bacteriophage therapy long after the rest of the
world had given up, actually into the late 1940's.
They published several articles during World
War II reporting treatment of battlefield wound
infections with phage.

22. Note 19.

23. As one bacteriophage therapist in India wrote:
"In a disease so fatal as cholera, the evaluation
of the use of bacteriophage on alternate cases in
villages is not possible. It would certainly result
in a riot should one form of treatment seem less
efficacious than another."

24. Morlson, J., and Vardon, A. C: A cholera and

dysentery bacteriophage. Ind. J. Med. Res.
17: 48, 1929.

25. Compton, A.: Antidysentery phage bacteriophage

in treatment of bacillary dysentery; record of
66 cases treated, with inferences. Lancet 2:
273, 1929.

26. Though therapeutic application of bacterio-
phage proved valueless, its later use in typing
and genetic research has lent enormous im-
portance to the discovery of Twort and d'Her-
elle.

27. See d'Herelle, 1930, preface, p. v-vi.

FELIX n'HERELLE AND BACTERIOPHAGE THERAPY

123

Other sources consulted:

Adams, Mark H.: Bacteriophages. Interscicncc Pub-
lishers, New York, 1959.

Ackerknecht, E. H.: A Short History of Medicine,
revised edition. Ronald Press Company, New
York, 1968.

Lewis, Sinclair: Arrowsmith. Harcourt, Brace and
World, New York, 1952 (Originally published

1925).

Obituary notices of Felix-Hubert d'Herelle:
Nature 163: 984, 1949 (by Compton).
J. Int. Coll. Surg. 12: 597, 1949.
Ann. Inst. Pasteur 76: 457, 1949 (by Pierre Lepine).

The Public Practice of Midwifery
in Philadelphia

By W. ROBERT PENMAN, m.d. 1

IN Philadelphia, Pennsylvania, in 1835,
pregnant poor women had extreme
difficulty in obtaining any kind of care
for their confinements.

At that time in the city, there were only
two institutions offering "public" service
to the poor: the Lying-in Department of
the Pennsylvania Hospital and the Phila-
delphia Almshouse (or "Blockley," as it was
sometimes called after it moved to its
present location in Blockley Township in
1834).

Both institutions had limited facilities
and could not service the needs of the poor
women of Philadelphia, nor did these in-
stitutions have the confidence of the poor.
People knew that when women went there
for their confinements they might die from
puerperal infection or "child bed fever."
Those who could not avail themselves of
the public service of these two institutions
might be cared for by the Philadelphia
Lying-in Charity, established in 1828 by
Dr. Joseph Warrington 2 . Several small
dispensaries, including the Philadelphia
Dispensary, arranged for doctors to de-
liver women in their homes. The poor
were thus badly cared for, and dedicated
physicians of Philadelphia were profoundly
disturbed.

Dr. Jonas Preston was one of the leaders
in the movement to correct this situation.
Born in Chester County, Pennsylvania, in

1 20 State Road, Paoli, Pennsylvania 19301.

2 Joseph Warrington, m.d., (1805-88) received his
medical degree at the University of Pennsylvania in
1828. In addition to organizing the Lying-in Charity
of Philadelphia, Warrington wrote treatises on nurs-
ing (1839) and obstetrics (1842). See also Henry, F. P.:
Standard History of the Medical Profession of Phila-
delphia. Chicago, Illinois, 1897, p. 420.

1764, the son of a Quaker physician, he
was instructed in the practice of medicine
by Dr. Thomas Bond of Philadelphia and
became a successful practitioner of mid-
wifery in Chester, Pennsylvania, later
moving to Philadelphia in 1812. He was a
member of the legislature for many years,
serving both in the Assembly and the
Senate. After moving to Philadelphia, he
took an active interest in several institu-
tions in the city, such as the Pennsylvania
Hospital, Friends Asylum, Penn Bank, and
the Schuylkill Navigation Company. He
was an excellent and shrewd businessman
and was able to amass a substantial fortune
through wise investments, in real estate
and other ventures, of his own money and
his wife's inheritance. He was very active
in the Schuylkill Navigation Company
and also had extensive real estate holdings
in Norristown, Pennsylvania (1, 2). In his
will made out in 1834, he noted the des-
perate plight of the poor pregnant women
of the city and stated "that there ought to
be a lying-in hospital in the city of Phila-
delphia for indigent married women of
good character distinct and unconnected
with any other hospital where such fe-
males may be received and be provided
with proper obstetric aid for delivery,
etc." (3).

He bequeathed a sum of four hundred
thousand dollars for the founding of such
an institution. He died in 1836, and im-
mediately the trustees of the will at-
tempted to implement his directive. In
order to obtain the experience and the
advantages of the lying-in hospitals of
Europe, the Board of Managers hired Dr.
James Bryan to go to Europe for such a

124

THE PUBLIC PRACTICE OF MIDWIFERY IN PHILADELPHIA

125

survey 3 at a cost of $500 (4). The trustees,
cognizant of the vastness of the problem
and also aware of their ignorance of the
situation, had on August 2, 183G, re-
quested by letter that a committee of
physicians from The College of Physicians
of Philadelphia be appointed to investigate
the subject and make recommendations
for the proper construction of a lying-in
hospital. The committee of the "Preston
Retreat" consisted of John M. Ogden,
John M. Frailey, James Martin, Philip
Price, and Samuel Maydoch. The College
of Physicians immediately appointed a
Standing Committee on Midwifery, with
Charles D. Meigs 4 , Chairman, and Doctors
Kuan 6 , Huston 6 , and Gebhard 7 , members.
This committee replied to the Preston Re-
treat on November 15, 1836 (5).

The report is cogent, thorough and
timely. The correspondence and the report
of The College of Physicians are printed
here in their entirety.

TO THE COLLEGE OF PHYSICIANS OF PHILADELPHIA

Respected Friends:

The undersigned are a committee of the
Preston Retreat, to procure plans for a suitable
building or buildings for that institution. They are

s The Bryan report was made after the Meigs re-
port. Bryan investigated European hospitals in
1838—40, sending back multiple reports. He also
supplied comments while the building was being
erected. He became professor of surgery at the medi-
cal school in Castleton, Vermont, from 1840-44.

'Charles D. Meigs, m.d., (1792-1869) received his
medical degree at the University of Pennsylvania in
1817 and went on to become professor of obstetrics
and diseases of children at Jefferson Medical College.
He was also famous as an adversary of Oliver
Wendell Holmes. See Kelly, H. A., and BurTage, W.
L.: American Medical Biographies. Baltimore, 1920,
p. 777.

3 John Ruan, m.d., (1771-1845) received his medi-
cal degree at Edinburgh, Scotland.

"Robert Huston, m.d., (1794-1864) received his
medical degree at the University of Pennsylvania in
1825 and held Meigs' position in 1838.

7 Lewis Gebhard, m.d., (1791-1873) received his
medical degree at the University of Pennsylvania in
1813.

fully impressed with the importance of so con-
structing the Hospital as most effectually to guard
against the spread of those diseases to which females
are liable during the period of their confinement.
In order to perform the responsible duty devolved
upon them in the best manner the committee are
anxious to receive all the information that can be
imparted by those who have had experience and
occasion to reflect upon the subject of their enquiry.
By the Medical Faculty they must chiefly expect to
be enlightened, and they appeal to you as an
organized body of the Profession, from whom they
may expect the most important suggestions to guide
them to their conclusions. The lot that has been
selected for the Preston Retreat is a large square of
ground, upwards of 490 feet in length by upwards
of 417 feet in width, with wide streets on two sides,
the lot and surrounding streets comprising an open
area of more than eight acres, on a high gravel soil
that will secure dry foundations. The main building
will face southward on Hamilton Street between
Schuylkill, Second, and Third Streets.

We most respectfully ask of you to (give)
the subject your careful attention and shall be grate-
ful for all the light you may shed upon it.

We are very respectfully,
Your friends

John M. Ogden,
John M. Frailey,
James Martin,
Philip M. Price,
Samual Maydoch,

8 mo (Augt) 2, 1836

• • •

Philadelphia, Dec. 5, 1836

Dear Sir:

I beg leave to hand you, for the Trustees of the
Preston Retreat, a report of a committee of The
College of Physicians, of Philadelphia. The Com-
mittee consist of Drs. Meigs, Ruan, Huston, and
Gebhard. The report was drawn up in obedience to
a resolution of the college; and when considered, at
the Meeting held on the 15'* of last month, it was
directed to be presented to your Trustees, and ac-
companied with such verbal explanations as we
might deem expedient.

At the same meeting, the following resolution was
passed, and directed to be handed to the Trustees
of the Preston Retreat. "Resolved, that this college
recommend to the Trustees of the Preston Retreat,
the erection of a principal building for offices etc.,
with one or more flank buildings for the accomoda-
tion of patients, detached from the main building;
to consist of a range of rooms, open back and front,
so as to allow of the most ventilation."

Should the Trustees of the Preston Retreat think

126

W. ROBERT PENMAN

proper to ask for verbal explanations, I shall thank
you to signify their wishes to me; when I shall take
pleasure in calling our committee together for that
purpose.

I am, dear Sirs,
with the greatest respect,
Your obedient servant,
Ch. D. Meigs,

To Mr. Ogden

COLLEGE OF PHYSICIANS

Philadelphia, Nov. 15, 1835
The Committee of the College, to whom was re-
ferred a letter from John M. Ogden and others, a
committee of the Preston Retreat Society, report
that,

The benevolent Founder of the Lying-in Hos-
pital, about to be erected in our City, was desirous
that the Charity which bears his name, should
furnish to parturient women, not only all the aids
that are esteemed indispensable for their security
and comfort, whilst in travail, and the care and
watchfulness over them, required during the period
of convalescence; but also, an immunity, as far as
practicable, from those disorders that are most
likely to spread, in similar institutions, and which
have rendered many of them Pest Houses, rather
than Asylums, or Retreats from the dangers and
anxieties of the puerperal state.

In constructing a house, or houses for the use of
Dr. Preston's Retreat, it was thought incumbent on
the gentlemen charged with that important trust, to
inquire into the sources and causes of danger to
women congregated in such establishments; and they
have, accordingly, applied to the College, as a
Corporate Scientific Body, to whom they might, with
confidence look for correct and judicious opinions
upon the subject. It would be easy to reply to the
inquiry thus addressed to the college, in a few
words; and it would probably be the unanimous
opinion of the body that the disorder most sedu-
lously to be guarded against, as such as are found
to arise from the collecting a great number of
puerperal women within the walls, and under the
one roof, of the same building; and such as depend
upon keeping a lying-in apartment always occupied
without intervals of time during which it ought to
be completely vacated, cleansed, and ventilated; and
further that the disease which is esteemed to be
most dangerous, and most likely to spread is
Puerperal Fever, better known to the public by the
title of Child Bed Fever.

Notwithstanding this disorder is in its nature
most dangerous and the consideration of it alone,
would demand the wisest precautions against its
introduction and spread in the hospital, there are

several other maladies, that may, upon occasions,
get footing in a badly constructed hospital, and
become productive of extreme distress, and even of
great mortality; particularly, if all the wards should
be covered by the same roof, and admit not of a
complete isolation and purification. It is sufficient,
in this connection to mention scarlet fever, whoop-
ing cough, measles, varioloid, and Trismus of in-
fants, and of which by spreading among the inmates,
would serve to bring reproach upon the Foundation,
diminish its usefullness, and cause many to fall
victims, who might escape, but for the misfortune
of having entered an ill constructed retreat from
dangers which they might avoid at their own homes:
Such diseases might be rife in the hospital, without
any extensive prevalence of them among the other
population of the city. Great good can be done in
this community by furnishing to the inmates of the
Preston Retreat, all the aids and comforts appropri-
ate to their condition, and the true design of the
worthy founder will in so far be fully attained and
fulfilled; but if a faulty plan should be adopted,
the attack and spread of dangerous diseases will be
so far invited and promoted, that their occasional
appearance there in, will be inevitable, the Will de-
feated, and his munificence become an injury and
a mockery to the poor, rather than a great blessing
as he most piously and humanly desired.

Under what circumstances then, are parturient
women found to be most secure from the dangers
of Childbirth? It is invariably admitted that
parturition is accompanied with very little mortality
in private practise. The mortality varies according
to the season, as healthy or sickly, and to the range
of the cases, as occuring in the higher, the middleing,
or the lower walks of life; being greatest in the
latter, on account of the want of many comforts, or
necessaries as to lodgings, food, clothing, ventilation,
etc.; but, in all these walks, the security is very great
in private practise.

The contrary obtains, where many women are
confined under the same roof; or where they follow
each other in constant succession as tenants of the
same wards of a hospital; for not only is there, under
such circumstances, a great proneness in the women
to be affected with childbed fever; but, the infants
of the house are also the frequent victims of Tris-
mus, or nine day fits. These disorders are not only
more common, but far more fatal and unmanagable,
in the hospital, than in private practise; and can
only be effectively obviated or prevented in the very
place, and design, for the erection of the hospital.

In as much, therefore, as private confinements are
safest both for mother and their tender offspring, it
is impressed upon your committee as one of the
most important and evident facts in this relation,
that all lying-in establishments ought to be made as
far as possible, conformable in respect to comfort

THE PUBLIC PRACTICE OF MIDWIFERY IN PHILADELPHIA

127

and security, to the private dwelling, and dispense
all the advantages of the accouchement at home.
They consider that no cleanliness, no mere ventila-
tion, no regulations, should be deemed sufficient
guarantees against the introduction and spread of
puerperal fever in a great Lying-in Hospital, all the
wards of which are included with in the same walls,
and even by the same roof. There is sufficient both
of reason and authority, to convince us, that, the
poisonous air once generated in the house, passes
along the corridors ascends the stairway and infects
the building from the basement to the highest
stories. Without pretending to determine what is
the nature of the poisonous exhalation, or whether
indeed, it be a substantive poison that produces
these effects, past experience warns us of profuse
dangers, and exhorts us, when about to lay a new
foundation, for the benefit of succeeding generations,
to attend to the dictates of reason and prudence and
to depart from the old and vicious methods, by
adopting a new one likely to make the house forever
secure from the common reproach of similiar in-
stitutions. Your Committee are free to say that the
Preston Hospital ought never to deserve the name of
Pest House, considering the light possessed upon the
subject at the present day, and the ample means
appropriated for its erection on an improved plan.

In addition to setting forth the advantages of
private practise as to the greater security of patients
it behooves the Committee to lay before the College
some statements of the results of the Public, or
Hospital practise of midwifery and for this end they
beg leave to submit the following table which they
have taken from the valuable publication recently
made by Dr. Collins, late Master of the Dublin Ly-
ing-in Hospital. It comprises a statement of the
causes of death, in one hundred sixty four women,
who died there, out of sixteen thousand four hun-
dred and fourteen females delivered in the house,
during the seven years of Dr. Collins' Mastership.

From Dr. Collins' table it appears that fifty nine
out of the one hundred and sixty four deaths, more
than one third of the mortality were occasioned by
puerperal fever alone; and that, during a period
when no very great or extraordinary prevalence of
the malady existed, Dr. Collins remarks that, of the
16,414 women delivered, one hundred sixty four
died, or one in a hundred; but, he says that if we
deduct the deaths from puerperal fever which may
be considered accidental, the proportion is greatly
diminished; \iz. to one in one hundred fifty de-
liveries; and again, if we abstract those deaths
from causes, not the results of child birth, marked x
thus in the Table, the mortality from effects arising
in consequence of parturition is reduced to one in
two hundred forty four cases.

The Committee think that the data obtained in
the above Table are highly worthy of the attention

TABLE

x Diarrhoea I

x Typhus Fever 5

Rupture of uterus or vagina 32

Uterine I hemorrhage II

x Puerperal Fever 59

x Inflammation of Brain 3

x Ulceration of Intestines 3

x Hectic fever I

x Grief, apparently 2

x Stricture of intestines 1

Effect of tedious and difficult 1 1
labor

Convulsions 2

x Hydrothorax 2

x Pericarditis I

Peritoneal Inflamm

The Placenta retained 4

x Abcess in Spinal Canal 1

x Lumbar abcess I

x Phthisis 2

x Acute bronchitis 1

x Anomalous disease 12

x Diffuse inflammation 1

x Abcess in Abdoman 2

Sloughing of vagina 6

of the Preston Retreat Society as obtained in a
hospital acknowledged, in general, to be the most
admirably managed and it might suffice for the
purpose of their information were it not that other
places and institutions have been less fortunate.

For example, in the years 1819 and 1820 there
were delivered in the Maternite at Paris 4924 of
whom 1177 were attacked with puerperal fever,
nearly half of which cases proved fatal. Tenon, who
has written a memoir on the Hospital of Paris,
shows that in the Hotel Dieu, from Jan. 1, 1779 to
Dec. 31, 1780 there died one in fifteen and two
thirds of the women delivered in that hospital.

The younger Baudelocque has also calculated the
mortality oj: the Maison de Accouchements for a
period of 11 years from Jan. 1, 1814 to Dec. 31, 1824,
and informs us, that, one woman died out of some-
what less than every 22 delivered. According to the
same author, the mortality was nearly the same for
several other periods; for example in 31 years, there
were confined at the Maison de Accouchements
61,647 of whom 2777 died, or one in twenty one and
a fraction.

In a printed abstract of the Registry kept at the
Lying-in Hospital in Dublin, we observe that from
Dec. 8, 1757 to Dec. 31, 1828, there were admitted
123, 790 women of whom 1420 died or one death in
eighty nine admissions.

There are numerous statements of average mor-

128

W. ROBERT PENMAN

tality, and of mortality under peculiar circumstances
which it would be useless and tedious to cite here;
but, we shall not overlook a pamphlet entitled,
"Some Accounts of the Pennsylvania Hospital," in
one of the pages of which we learn that, the Ly-
ing-in Department of that house as established in
1803, and that up to the 28 th of April 1832, there
had been admitted 747 women, 54 of whom left the
house undelivered making a total of 693 women de-
livered in that Department. Of those women 35
died; or one in 19 */$ nearly, of all the patients.

These calculations of Hospital results, are ex-
tremely important but we think that an inference
particularly instructive may be drawn from the
astonishing difference in the Dublin and Phila-
delphia Houses; it is this, that where many sick
individuals are congregated under the same roof,
disease is prone to break out, and spread among
them, and prove rebellious under medical treat-
ment. It is not improbable, that the epidemics of
puerperal fever, that have on several occasions,
desolated the Lying-in Ward of the Pennsylvania
Hospital may be satisfactorily traced to some con-
nexion with Erysipelas, which at times is found to
infest the wards of that Establishment; evincing an
impure state of the air under that roof, notwith-
standing the greatest precautions that are there
adopted, on the subject of cleanliness and ventila-
tion, equal, perhaps, to what are found in the best
private dwellings. The whole number of persons
under medical and surgical treatment there is or-
dinarily rising of two hundred, and the erysipelas
which occasionally afflicts them, is on reasonable
grounds, suspected of having a cause, common to it,
and to the child bed fever.

To show how far the congregation of many pa-
tients within the same enclosure may, by inference,
be accused of producing very pernicious tendencies
among them, it may be properly mentioned here,
that the Dublin Lying-in Hospital is thought to be
one of the best institutions of the kind in the world.
The building is of three stories, each floor divided
by a spacious corridor, extending through the house,
length wise and bisected by the stair ways; which
gives twelve large wards, each provided with 8 or 10
beds. There are two other small wards at the end of
the edifice. Now, this house, tho capacious, admir-
ably ventilated and scrupulously clean, has been the
seat of the most fatal epidemics of Child Bed Fever.
That disease has prevailed there, in the years, 1767,
1774, 87, 88, 1803, 10, 11, 12, 13, 18, 19, 20, 23, 26, 28,
and 29. In the epidemics of 1819 and 1820 alone,
there died, 114 women.

All experience indeed, goes to confirm the opin-
ion that a great many lying-in women ought not to
be assembled in one building; and that pregnant
females ought not to continue inmates of wards con-
taining the occult causes that predispose them to

the assault of the disease in question. Universal ex-
perience teaches, further, that once established in
the wards the causes can not be easily ejected or
eradicated, by washing or scrubbing, by chlorine, by
fumigation, by painting, lime, washing, nor, in short,
by any known means except the vacation of tfie
apartments, and the suspension of its usefullness for
a greater or less duration of time — such a room is
forbidden ground for pregnant women; if they in-
habit it, they acquire in it the fatal predisposition
whose development and lethal powers, only demand
the throes and excitement of labour, or some of the
slight affections generally ensueing childbirth.

It is well known here, that this predisposition
has been fatal in the Pennsylvania Hospital, and the
cause so previously seated in the Lying-in Ward*
that they have on several occasions been, through
necessity, entirely closed against patients for a long
time together. Thus suspending the functions of
Charity. The disease has reappeared among the first
admissions and the Managers, most wisely and hu-
manly, at length resolved to place the Lying-in
Departments in a separate building — which is the
reason why patients have now for some time been
accommodated pleasantly and we hope safely, in the
basement story of the West's Picture House.

Your Committee do not esteem it, apart of their
duty, further to review the history of Epidemic
Puerperal Fever. They conceive it to be a settled
opinion among medical men that child bed fever
and Trismus are the bane of such establishments,
and are prone to excessive violence in proportion
to the want of fresh air, the absence of cleanliness,
and the populousness of the wards that are formed
under a single roof. It would be an easy task for
them to detail the melancholy history of the malady,
but, the Table representing the causes of death in
the 104 victims at Dublin, already submitted leaves
perhaps, with sufficient cleanness to set forth what
are the ordinary disorders attendant on parturition
and what important influences may be exerted in
favor of the patients, by a judicious arrangement of
the house, in its original plan.

A few reflections upon the probable wants of our
community in reference to the comfort and protec-
tion of poor lying-in women, seem to us so oppor-
tune for the present occasion, that we shall seize it
to lay before the College our views in relation
thereto.

There are but two lying-in Hospitals in Phila-
delphia, one of which is the Lying-In Department
of the Pennsylvania Hospital and the other the
Lying-In Wards of the Philadelphia Almshouse.
There should be taken, also, into consideration the
Philadelphia Lying-In Charity, which provides for
attendance upon sick at their own houses; and some
females are relieved by the several dispensaries,
upon application made at their offices.

I I IK P115LIC PRACTICE OF MIDWII KRY IN l'1 1 1 1 . A I ) III' 1 1 1 A

129

The Pennsylvania Hospital and the Almshouse
relieve about one hunched and fifty annually and
the other institutions above named probably re-
lieve an equal number; so that it appears the Public
Charity of Philadelphia caters to about 300 women
in labour per annum.

The total number of children born here in a.d.
1835 was 7856, as ascertained from the returns to
the Health Office , made by 170 practitioners of
midwifery. Computing then, that there were de-
livered in that year 7856 women, the 170 practi-
tioners would each have 40 obstetric cases per year,
if they were equally divided among them; but,
some medical persons have 200 patients per year,
others 100, 90, 70, etc., leaving to many of their
bretheren but a few cases in that branch of prac-
tise, for which so eager a competition exists, and
which is supposed to lead to the highest success in
medicine, more certainly than any other depart-
ment of practise. It is supposedly under such cir-
cumstances, that puerperal women will often be
left to suffer for the comforts and aids that pro-
fessional men alone can give, or that many exam-
ples will be found in this community of women
applying in vain for medical assistance in the trying
hours of travail or in a subsequent confinement and
indisposition, or illness. We are too well acquainted
with the liberality of our brethren to suppose it
possible.

To show that our poor do not lack, for as-
sistance on these occasions, it is sufficient to state
that, the comforts and accomodations of the Lying-
in Department of the Pennsylvania Hospital great
as they are, are yet incapable of attracting more
than about 60 women there in each year, which
could not be the case were the wants of that class
of patients more pressing than they are at present.

Let the above specified circumstances have due
weight, and they will convince the College that the
new Hospital will not, probably, be crowded with
patients for some years to come; and consequently,
will not for some time require the erection of very
expensive buildings; considering too, that complete
isolation of the wards affords the surest means of
obviating the spread of disease; that, if the disease
should epidemically attack the inmates, it could
only be eradicated by closing the house for a season,
thus interrupting or suspending the Charity (sup-
posing it to be contained in a single house). Lastly
considering that many years must elapse before the
demand for aid shall become clamorous, in this
community, we feel convinced, that, if guided only
by views of the personal accommodation of each
woman we ought to recommend the construction of
a number of small houses, so as to give each woman
a separate lodge. Such a plan as this, however, we
can not bring ourselves to recommend in the present
instance, for many reasons, in addition to those

connected with the greater cxpensiveness of such
a method. There may be several good methods of
arranging the Hospital buildings, either of which
could with propriety be selected by the Preston

Society.

The Committee, not being in possession of the
requisite knowledge and taste in Architecture, have
had conversations with an eminent person in that
profession in order to ascertain whether the most
fastidious taste could not be fully gratified in the
erection of several small buildings, instead of one
principal structure. They were pleased to learn
that a good architectural design would not be in-
compatible with the erection of a central building,
on the south front of the lot, and of several de-
tached edifices on a line with it ranging east and
west. These buildings might be 38 by 40 feet square,
two stories high, with marble fronts, divided by a
blank wall from north to south, giving four rooms
on each floor, communicating by a door between
the north and the south rooms, but admitting of no
communication between the east and west room.
Piazzas on the northwest, north, and northeast sides
of the buildings would afford a sufficient promenade
for the patients, and admit of a convenient access
to the upper floor without any direct communica-
tion of the lower with the upper wards.

The west, north, and east windows should be
constructed so as to open out on the piazzas, by
opening on hinges, with ventilation shutters on the
outside. The south windows should be made in the
ordinary manner of constructing sash. A center
building might be used as office-residence for the
Steward and Matron, and apartments for women
waiting for the period of their pregnancy and for
other purposes. With one center building, and two
out buildings of the form and size indicated, the
hospital could go into early operation. The out
buildings would cost 5,000 dollars each; and the
principal edifice could also be constructed for a
moderate sum if divested of useless moment.

Each out building would accommodate 16 pa-
tients, having eight wards, in each of which two
patients would be accommodated. As the north and
south wards would communicate with each other
by a door, one nurse could conveniently take care
of four women and four children. Eight nurses
therefore, would serve the whole hospital, even sup-
posing two out buildings to be completed and to
contain as many as 32 women and an equal number
of children. It is highly probable, however, that a
smaller number would suffice for years to come.

Should the above plan be adopted, it is reason-
able to conclude that if well administered, it could
for ever be kept free from the epidemic which is
most to be feared and guarded against. A perfect
security would probably follow that adoption of
the method now used at the Dublin Hospital —

130

W. ROBERT PENMAN

videl. The wards should be numbered 1 to 16, and
used in succession, no ward to be made use of after
having received and discharged its confinement,
until every other ward, has been likewise filled and
emptied. During the time of each apartment being
unoccupied, it could be thoroughly cleaned and
ventilated, and freed from all infections or mias-
matic exhalations — or it could be sequestered from
the establishment for weeks or months, without
interfering with or in any wise suspending the
general and beneficicnt functions of the whole
Charity.

The lot on Hamilton Street is large enough to
admit in future times, of the construction of ranges
of separate buildings on each of its sides, sufficient
in number to accommodate the poor lying-in women
of an immense capitol.

If that lot should retain its present lofty eleva-
tion, instead of being reduced to the common level,
its sides might be supported by a wall of stone, and
the buildings could then have for their site a noble
terrace, which would raise them above all the sur-
rounding edifices, exposing them to the fresh
ventilation and presenting a most attractive spec-
tacle in their simplicity, symmetry and order, as
well as the beauty of the material of their several
fronts. The centre would compose a court or garden
adorned with trees, shrubs, and grass, both con-
ducive to the beauty, salubriousness, and comforts
of the institution. Such an Hospital would be
highly attractive to the better set of poor patients;
it would be healthy, private, easily administered;
without the noise and confusion of a single edifice;
cheap in construction, and capable of a gradual
extension, proportion to the increasing wants of the
community in future years or generations and
leaving an ample remainder of the Preston legacy,
for the entire comforting and accommodation of the
sick.

Should the Committe of the Preston Society on
the other hand resolve to build a single house; then
the committee recommends the adoption of a plan
similar to that of the City Hospital on Bush Hill;
have a principal building with detached wings, two
stories high and 20 or 22 feet in depth, admitting
of the erection of a number of wards of 17 or 18
feet by 20 or 22 feet — the south front provided with
piazzas, above and below as is observed at the City
Hospital.

A Hospital erected on this plan presents many
advantages as to accessibility and the desirable iso-
lation by means of blank walls earned up from the
cellars to the roof, being each alternate %vard —
which ever of the methods may be chosen. Your
committee will feel satisfied that the Directors will
have acted with wisdom and humanity, in adopting
in either case a method that must most certainly
obviate the shocking occurance of epidemic puer-

peral fever, which no medical or other person,
who has witnessed such an indomitable disorder,
could think of with out discomposure.

V'our Committee having laid before you what they
consider correct principals in the important ques-
tions submitted to their consideration deem that
their task is now fulfilled, without entering into
many minute details, as to the arrangement or
placing of doors, windows, fireplaces, etc., etc.. They
will find themselves at all times happy, in being
enabled to give their opinions upon those subjects,
if invited to do so by the Preston Retreat Com-
mittee.

Which is respectfully submitted.

Charles D. Meigs, Jr., Chairman

The Standing Committee on Midwifery

The Board of Contributors of the
Preston Retreat whole-heartedly accepted
the report of the Standing Committee on
Midwifery of The College of Physicians
and began to implement it immediately.
On June 13, 1836, the Preston Retreat Bill
was presented to the Senate in Harrisburg,
Pennsylvania. The Senate and House of
Representatives in the General Assembly
in Harrisburg appointed 114 members to
the Board of the Preston Retreat and in-
corporated it as a Society. The members
had to pay $5.00 per year or $30.00 as a
life contribution. The affairs of the Insti-
tution were to be conducted by a Board of
Managers of 24 Contributors to be elected
annually by ballot the second Monday in
January of each year. The Board of Man-
agers, in turn, were to appoint a Visiting
Committee of twelve respectable females
from the City and County of Philadelphia
and the County of Delaware. This com-
mittee had power to select and remove
physicians, nurses and other assistants from
the Institution.

The ground upon which the Preston
Retreat was to be built was purchased on
August 1, 1836 from John McAllister for
537,000. It consisted of eight acres and was
between Hamilton and Morris Streets, the
Schuylkill River and Third Street in the
District of Spring Garden. John Sergeant
was the lawyer handling the transactions
for the Preston Estate. Four architects

THE PUBLIC PRACTICE OF MIDWIFERY IN PHILADELPHIA

131

were invited to submit plans for the Re-
treat. On February 20, 1837 the Preston
Board appointed Thomas U. Walter to be
the architect, and the Standing Committee
on Midwifery of The College of Physicians
nuclei the Chairmanship of Charles D.
Meigs accepted the design. The corner-
stone was laid on July 17, 1837.

Construction was immediately delayed
because the marble from the Chester
County Quarries, "where it is required to
be obtained," was in not large enough
supply. Patience was needed, for by 1840
the Retreat was still under construction
and had cost $80,000.

The estate to create the Preston Retreat
came in part from the sale of lands of St.
John's Church in Norristown, Pennsyl-
vania, and from other securities. Most of
jthe stock was in the Schuylkill Navigation
Company which failed in the 1840's. Be-
cause of the ensuing lack of funds, the Re-
treat was not finished nor opened until
1865. In January of 1865 the Board of
Managers sold 25,000 shares of stock in the
Schuylkill Navigation Company at $1.00
iper share, netting $25,000. Jay Cooke and
Company at this time also purchased the
Schuylkill Navigation Company lands at
la cost of $290,000. With this money, the
Board of Managers then repaired and
furnished the Preston Retreat in 1865 at a
cost of $361,734 and opened it for business.

In October 1865, the Board of Managers
appointed Dr. William Goodell (7-10) of
West Chester, Pennsylvania, the first resi-
dent director and steward of the Preston
Retreat, with his wife, Caroline Darlington
Bell (of West Chester, Pennsylvania) acting
in the position of Matron of the Institution.

In the spring of 1866, Mr. William
Saunders, of Washington, D.C., planned
the ornamentation of the grounds of the
Preston Retreat.

Under the mastership of William Good-
ell, the Preston Retreat flourished and be-
came a showcase throughout the country
for the public practice of midwifery.

Goodell very ably implemented the recom-
mendations made in the exhaustive Meigs
report and even enlarged upon it. Under his
mastership, he supervised the delivery of
2444 women.

In August of 1874 he reported on his
stewardship of the Preston in the Obstetric
Journal of Great Britain and Ireland. He
reported on his first 756 deliveries. He had
had six deaths during this period for an
incidence of one death for every 126 de-
liveries. The deaths were: two from sepsis,
one from a ruptured pelvic abscess, one from
hemorrhage, one from acute chorea, and one
from caries of the petrous portion of the
temporal bone. Thus, his mortality from
the dreaded puerperal infection or "child
bed fever" was one in every 378 deliveries,
far exceeding the record of the famed
Dublin Lying-in Hospital.

Goodell was able to achieve this then
outstanding record in the public practice
of midwifery by the implementation of the
Meigs' report and by his own innovations:
early ambulation of the post partum
mothers, the avoidance of the routine post
partum enema, and scrupulous adherence
to an aseptic technique, with the insistence
on adequate ventilation in the wards at all
times. He prohibited the performance of
any autopsies by himself or his colleagues.
He advocated immediate postpartum
breast-feeding and forbade the use of the
then routine belly band on the infant. He
insisted that the nurses change their outer
clothing and wash their hands thoroughly
when leaving one ward and entering an-
other. He rotated the postpartum wards,
and when a ward was emptied, it was
washed from top to bottom and aired and
left vacant for two to three weeks. In labor,
he introduced the administration of a tea-
spoon of ergot when the baby's head
pressed on the mother's perineum. When
the mother entered the second stage of
labor and if the delivery did not shortly
ensue, he effected delivery with the vectis
or forceps to prevent his poor mainour-

132

W. ROBERT PENMAN

ished patients from becoming too fatigued.
He repaired all perineal lacerations with
silver wire in order to decrease the pos-
sibility of infection. When postpartum
vaginal examinations were indicated,
Goodell insisted on a thorough scrubbing
of the hands and then an immersing of the
fingers in a carbolic acid solution prior to
the examination. Because of the poor nu-
tritional state of the patients, they were
admitted to the Preston one or two weeks
prior to labor so that they might be
thoroughly bathed and cleansed and fed
properly to improve their nutritional and
physical state so that they could withstand
the rigors of labor. He obtained the per-
mission of the Board of Managers to keep
the women for up to four weeks after de-
livery in order to bring them back to good
health before discharge from the Preston.
In serious and unusual cases, he could,
with the approval of two thirds of the
Board of Managers, keep the poor women
up to twelve weeks. He also had permission
of the Board of Managers to board the
children under age seven for the entire
time while their mothers were confined in
the Retreat (6).

At all times, there was a constant de-
mand for wet nurses. Goodell usually had
about eighteen women willing to be hired
as wet nurses at all times, for which they
were paid 6-7 dollars per week (3).

Thus, through the implementation of
the Meigs report and under the diligent
and brilliant mastership of William Good-
ell, the Preston Retreat was able to create
a national model for the public practice of
midwifery and make such an institution
safe for all women. These innovations led
the way for the eventual change in the

method of delivery from all walks and
categories of life.

Acknowledgment

The author is indebted to the Board of Managers
of the Pennsylvania Hospital for permission to re-
print entirely their handwritten copy of the Meigs
Committee Report. Permission to use original ma-
terial of The College of Physicians was granted by
Dr. W. B. McDaniel, Curator of the Library His-
torical Collections.

REFERENCES

1. Kelly, H. A., and Burrace, W. L.: American

Medical Biographies. Baltimore, 1920, p. 938.

2. Wilson, J. G., and Fiske, J.: Appleton's Cyclo-

pedia of American Biography. New York,
1888, Vol. 4, p. 115.

3. Preston Retreat Papers, Pennsylvania Hospital,

Philadelphia, Pa. Miss Joyce Cooper, Curator.
Microfilm, American Philosophical Society,
Philadelphia, Pa.

4. Bryan, J.: Report on The State of the Lying-in

Hospitals in Europe to the Managers of The
Preston Retreat and to the Obstetrical Com-
mittee of The College of Physicians. Phila-
delphia, 1845.

5. Ruschenbercer, W. S. W.: An Account of the

Institution and Progress of The College of
Physicians of Philadelphia during a Hundred
Years from January, 1787. Wm. J. Dornan,
Philadelphia, 1887.

6. Goodell, W.: The Means Employed at The

Preston Retreat for the Prevention and Treat-
ment of Puerperal Infection. Obstetric Jour-
nal of Great Britain and Ireland, American
Supp., July-Aug. 1874.

7. Hirst, B. C: In Memoriam, William Goodell,

m.d. Transactions of the Amer. Gyn. Soc. 20:
539-17, 1895.

8. Parrish, T.: In Memoriam, William Goodell,

m.d., ll.d., Amer. J. Obstetrics, Vol. XXX:
827-37, 1894.

9. Kelly, H. A., and Burrace, W. L.: American

Medical Biographies. Baltimore, 1920, p. 448.
10. Wilson, J. G., and Fiske, J.: Appleton's Cyclo-
pedia of American Biography. Vol. 2, p. 679.

Notes on the History of Medicine in Hungary 1

By GE< >RGE P< >L( . \K, m i.

A YOUNG lad) . born in Budapesl .
w ho in. it i icd .in \im i. ill. in. latei
made .i nip around i lie world with
ho Famil) .mil published ,i travelog, which
became a bestseller. The siory was pre-
sented as il told l>\ the lady's little sun.
ll started as lollows: "My lather is a law
professor; m\ mothet is Hungarian."

Ii Minis thai being Hungarian is a
profession; our is assumed able t<> write
anil talk about a variet) i>l suhjccls with
the finesse of an expert. And so I was
invited id give this lecture mi medical
history.

As a visual aid. I brought along a print
ol an oil painting l>\ an unknown mastei ol
the earl) 18th Century. I he original was
found in an old pharmacy in Koszeg, a
town in Western Hungary. The picture
shows Cosmas and Daniian, the patron
saints ol physicians and pharmac isis | Figure
!)•

While preparing lor the talk. I (lis-
covered with regret thai I am old enough
in remember some ol the events which can
he considered medical history. The first
was the coincidence thai m\ professor ol
biochemistry in m) freshman year at the
medical school ol Szeged was Albeit
Szent-Gyorgyi, who won the first Nobel
prize for his country that very year. We
gave him serenades and we celebrated a
lot. hut we had fewer lectures than usual.
We were proud ol him, and so were the
people of Szeged, the center of the Hun-
garian paprika industry. The professor, ol
course, found a large concentration ol
vitamin C in that plant, lie also influenced

1 Set t ion on Medical History, The College of
Physicians of Philadelphia. II Kelmiarv 1'tfiO.

- Associate Professor of Pediatries and Physiology .
Department of Physiology, Division of Graduate
Medicine. The School of Medicine, University of
Pennsylvania, Phildaelphia, Pennsylvania 19104.

medical history in anothei way. Szent-
Gyorgyi helped great 1\ lo establish the liisi
democratic student oigani/alion in I inn
gary, which altei many decades ol still
Germanic discipline created a Ireei almos-
phci e ol si udent lai nil \ relal ionsh ip.

History became darker every year dur-
ing in\ medical school period, rhere was
increasing political pressure, discrimina-
tion, bookburning, and finally war, con-
centration camps and bombings. Physi-
cians weie not spared, and I losl many
good friends dining t hose tragh years. The

end came with a six week siege ol the
capital reminiscent ol the Imkish inva-
sion ol the 16th Century. These were haul
linns loi everyone, and physicians worked
heroically amid falling bombs, famine and

epidemic s.

Allei the wai there was a glimpse ol hope
lot freedom, and we weie lull ol optimism.
I was a Inst year resident when il was m\
dut) to appeal icgulaib ai the head-
quarters ol the American Military Com-
mission to pick up the penicillin shipments
donated lo my hospital. It was a wondei
chug, and we loved the Americans foi
it.

Soon new clouds gathered, new disciinii-
nations and new pressures, purges and
counterpurges, cultural deprivation and
diminishing freedom. Medicine again
shared in all this: therapeutic measures

for diseases weie ordered by law, educa-
tion was tightly controlled, and the prac-
tice ol medicine was reduced to assembly-
line work. The predictable reaction came
with the 1956 revolution, followed b) de-
feat in the lace ol overwhelming forces, and
mass exodus. I participated again, in a
small way, in history, when I left tn\
country with 7()() othei physicians (nearly
a 7% loss of medical manpower). This

133

134

(,I-.()R(,I I'OK.AK

In,. I. Cosmas and Damian. I'aiiiicd l)\ Kndic
S/as/, after a picture from the 18th Century.

was a grave (jiiesl ion ol conscience and
mu( h ol it is not settled to the vei y day.

You can see from the events of this rela-
tively shorl period that ihc history ol
medicine as well as the hision ol an\
art or science in Hungai\ is inl imately re-
lated to the political history of the coun-
try. This is one of the reasons why for-
eigners, who did not have the personal
experience ol being a Hungarian, have
trouble understanding Hungarian litera-
ture, poetry, music, etc. 1 will try to il-
lustrate this close relationship of medical
and political history in what follows.

The Magyars occupied the Carpathian
basin in 895 a.d. During the first fOO years
they led campaigns against the West and
got as far as France, but they were even-
tually driven back and forced to settle
within the natural boundaries of Hungary.
The consolidation was helped greatly by
a remarkable ruler, the first king, Stephen
I (later Saint Stephen). He not only con-
verted his people to Christianity in a

shorl period of time, but established a
nation on the basis of impressively broadi
minded principles. "Cuius linguae, uni us-
que maris regnum imbecille et fragile est,"
said Stephen, and lie could have been a
founding lather of America for his views
on the strength ol the multilingual state.
Alas, his teachings have been forgotten too
often dining the following 1000 years.

The Inst dynasty ruled Hungary for
about 300 years, dining which there was
productive consolidation of the country
with some expansive tendencies, leading to
the earh acceptance of an English-style
Magna Charta in 1222, but brutally in]
terrupted by the devastating Tartar inva-
sion ol 1211 12. Dining the slow recovery,
iIk ILrpad dynast) came to an end and
foreign rulers look over the throne. Fifty
years later there came an imperialistic
drive for expansion, marred by I lie
troubles that must be expected with such
policies, yet bringing some true renais-
sance- in the ai ts and sciences.

At the end of the 15th Century, the
Turkish attackers started threatening the
southern borders, and by 1526 a new
tragedy was complete. The nation fell
apart under the devastating sweep of the
Turkish armies. The mid- and southern
pot lions were under Turkish occupation
Idi mote than 150 years; the northwestern
pari was a kingdom under Hapsburg rule,
with sections of the people collaborating
with and others rebelling against Austria;
Transylvania in the East formed an inde-
pendent principality which collaborated to
some degree with the Turks, but was
troubled by Catholic-Protestant religious
rivalry of the princes.

When in 1699 the Turks were finally
driven out, with substantial Austrian help,
a shambles remained of what was once a
promising, developing country. The na-
tion predictably and promptly turned
against the Hapsburgs, which resulted in
an eleven-year revolutionary war against
Austria, led by Prince Rakoczi I. The

NOTES ON HISTORY OK MEDICINE IN HUNGARY

135

reaction was that absolutism was intensi-
fied, inflamed also by the fear of liberal
winds blowing from Paris after the French
Revolution. The vicious circle of oppres-
sion and national-liberal tendencies culmi-
nated in another bloody uprising in
1848-49, which again ended in a now even
more painful defeat. It took eighteen years
before the wounds were healed sufficiently
to result in a compromise leading to a few
decades of ill-at-ease prosperity and tran-
quillity. Some called this time "the golden
age." However, the morale of the country
was weak; with the teachings of Saint
Stephen all but forgotten, the nation fell
prey to the intrigues of the Viennese court
that tried to rule by turning the nation-
alities in the Carpathian basin against one
another. The internal strife was to be one
of the causes of World War I, and the re-
action to that was in turn to lead to the
second cataclysm.

The Medical Profession

The history of the medical profession in
Hungary started with the Benedictine
fathers brought in from Monte Cassino by
King Stephen. They built their first
monasteries and primitive hospitals nearby
in the eleventh century. Some of the ruins
of these are still present.

Monks were generally regarded as au-
thorities in medicine at that time. How-
ever, they soon became detached and with-
drawn into theoretical work in their cells,
and they let their helpers do the unpleas-
ant part of medicine. Thus, the jobs of the
surgeon-barbers, executioners, and other
lay medics came into being. The Tartar
and Turkish invasions wiped out many of
the inhabitants of the monasteries, and
therefore less and less learned people re-
mained.

Initial attempts to start higher educa-
tion in the country were also shattered,
and young men who wanted to study medi-
cine had to go abroad. For centuries the
schools in Bologna and Padova, Halle and

Heidelberg, Zurich, Leiden, Oxford and
mainly Vienna saw scores of Hungarian
students, poor and with the awkward
habits of their strange country. Noblemen
did not regard medicine as a desirable
profession for their sons, but they were
willing to support poor students in their
travels. Later, funds were provided by
some of the European universities, particu-
larly when, after the Reformation, Prot-
estants were not allowed into the places of
higher education in the country. Many of
these students remained abroad after
graduation, and Hungarian names were to
be found among the distinguished teachers
of many European schools.

After the Turkish occupation, the trend
reversed to some extent. The country was
in poor shape, its population severely
decimated. Even the Hapsburg rulers,
probably not without political aims, trans-
ferred various nationalities from other
parts of their Empire to Hungary. Many
brought medical skills, for example, the
Mennonites, who later were converted to
Catholicism and who had many accom-
plished physicians among them. The influx
did not produce a high level medical pro-
fession; it rather helped spread the various
forms of charlatanism. There were the
liniment and oil peddlers from the Slavic
regions, the herniotomes and lithotomes,
the occultists and the real witch doctors.
Laws were signed against charlatans as
early as the end of the 16th Century, but
they were not very effective.

It Was just before the great plague and
small pox epidemics of the 18th Century
that Queen Maria Theresa established the
first formal medical faculty at the Univer-
sity of Nagyszombat (Tirnau) in western
Hungary. At the opening of the school in
1770, five chairs were filled by German-
speaking Austrians. Protestants were not
admitted and neither were Jews (in Hun-
gary, where the rights of Jewish merchants
were assured by law more than 500 years
before this time). The graduates were not

136

GEORGE roi.GAR

licensed in the monarchy as a whole, only
in the Hungarian territories. This, and the
poor financial state of the school in its
first decades of existence, discouraged
many young men from enrolling. At the
same time, classes at the Vienna school
were overflowing with Hungarians, which
again worried some Austrians. But these
were the troubled times between the revo-
lutionary wars of Rak6czi and the 1848
rebellion. Hungarians could not expect
much help from their rulers. No medical
journal was permitted to appear in Hun-
gary, not even in Latin.

The first medical faculty moved to
Buda in 1778 with a three-year course, and
opened a five-year curriculum only after
1805. There was a little known partial
school in Transylvania, but more com-
plete medical faculties were not estab-
lished until around the turn of the cen-
tury.

The school in Buda and later the one in
Pest saw little excitement. Student disci-
pline was a lesser problem than nowadays,
but, ironically, at one time the students
had to be ordered by the university au-
thorities not to wear short hair, because it
was against good taste when everybody
wore it long. There was a brief open re-
bellion when, during the cholera epidemic
of 1831, the town was under quarantine
and the students wanted to break out and
go home to their families.

Public Health

The state of public health was under-
standably linked to the political events. In
times of war and occupation even mem-
bers of the highest nobility became louse-
infested, and various epidemics helped the
occupiers decimate the population. How-
ever, the Magyars were relatively clean
people, who liked bathing more than their
neighbors. The numerous spas and hot
springs which were and still are to be
found in various parts of the country
presumably contributed to their enjoy-

ment of bathing. Just as profoundly as the
Turkish invasion affected the fauna, flora,
and even the climate of the occupied parts
of the country, the ritual bathing habits of
the Turks were also instilled in the people.
Several of the original Turkish baths still
stand as historic monuments, and some are
even used.

The native population learned the hard
way to protect itself from the endemic dis-
eases spread by polluted waters and other
uncontrolled environmental factors. Wine-
drinking became universal when, during
the occupation, wells and creeks became
unreliable. Wine was probably the one
thing in which the Turks were not inter-
ested, since their religion prohibited its
consumption. It is a fact that immigrants
and visitors, unfamiliar with the local con-
ditions, fell victim to the endemic typhoid,
dysentery, etc., in larger proportions than
native Hungarians. Other major diseases
afflicting the people of the middle ages,
such as syphilis, lepra, tuberculosis, and
the great epidemics of plague and cholera
knew no national barriers and severely
limited the chances for quick recuperation
from the grave losses suffered by the politi-
cal events.

Learned physicians being as rare as they
were during the centuries before formal
medical education began, the people con-
sulted charlatans and relied on collections
of home-made remedies and proverbial
health advice for their complaints. Al-
manacs, published yearly and being the
only printed reading material next to the
Bible for most country people, contained a
wealth of popular medicine. For example,
the "Locsei Kalendarium" (Calandar of
Locse) of 1626 offers the following advice 3
for the first two months of the year:

January:

Don't suffer from bloodlett'n'
In the month of the Virgin,

Spice all the food you put away,
You will live to see many a day.

3 Translated by Steven Polgar.

NOTKS ON IIIMOIO ( >l MM»I< l\l l\ III \(.\K\

137

l ( hi u.ii \ :

Protect yoursell From the cold,
Don'l eal Bsh, drink wine that's old,
li won't linn you to take a bath,
Don'l 1 1 . 1 1 M i v oui Ik><!\ , sit i<> 1 1 1 .i i

foculai references to the various effects
ol the diet, Mich as the Eollowing, were
( ommonh i < >li I ovei meals:

fresh cabbage squeezes; cook its juice, that softens:
Eat one after the other, your stoinac li'll empi\
faster.

The- teller ol litis ban /not was allegcdh
repi iniaiided l)\ the hostess at ,i nobleman's
dinner table, because ii was considered un-
worth) ol high society conversation.

Ol course, serious monographs also were
written about various diseases. "A Short
Meditation on the Plague" In Mate
Csanaki (1634), a court physician, gives a
Father accurate symptomatology ol the
dreaded disease. The etiology as com-
monh accepted was "Cod's scourge for
punishment of our sins.'' Suggested treat-
ment: venesection, purgation, plasters,
and mainly the consumption of garlic. I he
latter was indeed used excessiveh In rich
and poor alike.

Cholera had its own literature in pro-
fessional as well as in line prose and
poetry. Particularly infamous was the last
big epidemic of 1S31. which triggered an
uprising of the peasants against the land-
lords, who were allegedly responsible for
the epidemic. The stor\ was spread inten-
tionally by political profit-seekers.

An interesting pamphlet about pipe-
smoking appeared in 1762. It gives a gen-
erally favorable opinion aboul the effects
oJ smoking, particularly in the morning
hours, when it supposedly clears the throat
and stimulates gastric function: but. some
warning is also voiced against its use to-
gether with excessive drinking, in which
case it may be deleterious to the lun»s and
tna\ even cause "dry cough" (tuberculosis).
It shows a remarkable degree ol loresighi
200 years before our Surgeon General's first
report on smoking.

Finally, toward the mid- 19th Century,
bettei medical education and medical care
began to make theii effects Eelt. Even the
almanacs were mote reasonable. In tli<
1841 edition, a mocker) ol the old-fash
ioned superstitious home remedies appears:

For tooth-ache take a birds' egg with some water
in your mouth; sit on the stove until the egg be-
comes soli boiled; you will never have a tooth-ache
again,

Hungarian medicine was not entirely
unknown abroad even long before the lust
Nobel 1'ii/e winner. Paracelsus traveled
extensiveh in Hungar\ in the I ")20's si ud\ -
ing medical practices, and, as a secondary
projet i . wines, rhe m< »si famous panat ea
ol 18th Centur) Europe was Aqua Regina
Hungaricae, a simple alcoholic extract ol
rosemary (spit it us rosmarini). The drug
was used l>\ the uppei (lasses (including
such notables as Louis XIV and Mine, de
SeVign£) for almost everything. It is difli-
culi to say what the secrel ol good pub-
lic ii\ is in sue h matters!

Important Figures

Finally, let me introduce a few ol the
historic figures of Hungarian medicine:

Agoston (Augustin) S( liopf-Merey was
the foundei ol the first pediatric hospital
in Budapest (1838). He also taught medical
history. Like main of his colleagues, he
participated in the IX1S-1!) revolution and
went into exile alter its defeat. He started
a hospital for sick children in Manchester,
England, with a native obstetrician named
Whitehead.

Jdnos (John) Bdkai, Sr. was born in 1822
ol German-speaking parents (his original
name was Bock). He took over Schopf-
Merey's hospital in IS 17 and became the
first professor and chairman of a pediatric
department in a medical school in the
whole of Europe. Bokai died from injuries
suffered in a fall while opening his new-
Hospital for Poor Children. He founded a
pediatric dynasty. Two ol his descendents

GEORGF POLGAR

Fic. 2. Janos Bokai, Sr.

Fk.. Frigyes Koranyi.

(Janos, Jr. and Zoltan) became professors
oi the new discipline.

Frigyes (Frederick) Koranyi (1828-1913)
was founder of modern internal medicine
in Hungary and started the long fight
against tuberculosis. He designed a steth-

Fic. 4. Janos Balassa.

oscope, which was widely used by inter-
nists, hut not In pediatricians. He also
started a dynasty: his son Sanrior and
several relatives became leading figures in
internal medicine.

Jdnos (jolni) Balassa was one of the
greatest surgeons of his time. He obtained
numerous invitations to chairs in foreign
schools, but he was an ardent Hungarian
and stayed home. He had a leading role in
the 1848 revolution and was jailed after-
wards, because of his name in surgery
the king pardoned him and he was given
his position again. This was the more re-
markable, because Balassa was the son of a
Protestant minister, an almost guaranteed
reason for exclusion from high posts.

Lajos (Louis) Markusovszky (1834-93),
also an eminent surgeon and Balassa's
disciple, was not so luck). He never be-
came professor because of his religion. He
was founder and long-time editor of the
(nst and still existing medical journal
(Orvosi Hetilap).

NOTES ON HISTORY OI Ml DM i\i i\ in NGARY

139

Fig. 5. Lajos Markusovszky.

Ii seems to me thai I should nol mention
Ignaz Scnnnchvcis (1818-1865) al all, be-
cause lie and his Hungarian origin are so
will known. Vet, when leading his stor\
again the other day. it struck me that the
drama ol this genius is more than the life
ol an individual. This man. who, with the
spontaneity of a Newton, discovered the
relationship between contamination by de-
caying human remains Erom the autopsy
table and the dreaded mass murderer,
puerperal lever, and who stayed with his
interpretation of this discovery al a time
when Virchow's cellulai pathology theorj
was at its zenith, fought lor his idea and
•<>> die life ol thousands of mothers with
fihe heroism ol all the Hungarian rebels
throughout the centuries. He was as sure
about the truth of his discovery as was
Galileo and (like that other genius) he was
diiu'ii to extremes, with the difference that
Senunelweis was fighting not onl\ loi an
idea hut lor 1 ives. He was (uiall\ declared
paranoid, which under the circumstances
was a reasonable conclusion, and com-

Fig. 6. Ignaz Semmelweis.

mined to ,m asylum. Several weeks latei he
died, ironically, from a wound infection
which he contracted during an operation
before his detention. His life was the
Hungarian tragedy: a spirit warning the
world, not heard, crying for help, not as-
sisted. He was also ,i true medical genius,
who preceded Pasteui In ihim years and
Lister b\ about twenty, with the new idea
ol infectious etiolog) ol diseases. I lis op-
ponents destroyed much ol their credii l>\
closing theii ears ami eyes Erom the truth.

REFERENCES

II \ i \- s \ . l-.: A Kossuth-idok Hazafias Orvosai. Kar-

pathia Kiad6, Munich, 1954.
Macyary-Kossa, J. V.: Ungarische Medizinische

Erinnerungen. Danubia, Budapest, 193").
TrocsAnyi, A.: Rigi Vildg, Furcsa Vildg. Bibli-

otheca, Budapest, 1958.
Homan, F. wn SzEKFUj C.Y.: Magyar Tortenet. Ki-

ralyi Magyar Egyctemi Nvomda, Budapest,

1935.

Medicine, Music and Academia

By V. WILLIAM SUNDERMAN, m.d., ph.d.,sc.d. j

BECAUSE ol in\ persona] associations
in medi< inc. music and universities,
il seemed appropiiate to lo< t is the
remarks tin's evening upon ilnce aieas ol
intciest. I hope that these areas might hold
some appeal to you.

Tirst, reference will he made to the con-
tributions to music by three eminent
physicians who lived during the past ccn-
tury. The second area will be directed to
the furtherance ol music through the
friendship ol Billroth and Brahms. Bill-
roth was one ol the woild's greatest sur-
geons. ,iud lira Inns was one ol the world's
greatest composers ol music. And, lastly,
a resume ol Brahms' Academic Festival
Overture will he given in older to capture
the spiiii ol the European universities
about a hundred years ago.

Contributions of Physicians
to Music

The ait of music and the priesthood of
medicine have been closely linked since
ancient limes. All of you know that Apollo
was the god of medicine, hut how many
know that he was also the god ol music?
The noblest conception within the range
ol Greek mythology places Phoebus-Apollo
as the god of both medicine and music.
Although music and medicine have been
closely related for thousands of years, never-
theless, at no time was the association more
intimate than dining the latter part of the
past century in the European universities.

In assessing the . development of music
during the past century, mention should
be made of the outstanding contributions
of three physicians, all of whom were con-
temporaries covering the period of 1821 to

1 Section on Medical History, The College of
Physicians of Philadelphia, 11 February 1969.

Director, Institute for Clinical Science, Inc.,
1930 Chestnut Street, Philadelphia, Pa. 19103.

18!) I, all of whom were professors in medi-
cal colleges ol European universities, and
all ol whom were dedicated to the further-
ance of music. These three physicians were
Helmholtz, Borodin and Billroth.

1 he In si physician to whom tribute
should be paid was Hermann von Helni-
hoh/ (1821-94) (Figure 1). Helmholtz
possessed one of the greatest scientific
minds of the nineteenth century and held
professorships in the medical colleges of
the Universities of Kdnigsburg, Bonn,
Heidelberg, and Berlin. W hile at the Uni-
versity of Kdnigsburg, he published his
monumental work entitled, The Sensa-
tions of Tone as the Physiological Basis of
Music. This book has been translated into
many languages and is still fittingly re-
ferred to as the "Principia ol Acoustics."

The second Aesculapian to whom honor
should be given was the great Russian
biochemist and professor in the Medical
College at the University of St. Petersburg
during the past century. Alexander Por-
firivich Borodin (1833-87) was the illegiti-
mate son of one of the Russian princes
(Figure 2). The name, "Borodin," was the
mii name of one of his father's slaves. (One
should, perhaps, realize that illegitimacy
does not preclude one from attaining high
honors in either music or medicine.) Al-
though Borodin was a distinguished scien-
tist, his claim to immortality arises chiefly
b om his accomplishments as a musical com-
poser which he himself regarded "as a
recreation, a past-time, and an avocation
that distracts me from my principal activity
as a professor." Borodin founded the famous
Russian Kouchka (Circle of Five) 3 whose
members openly revolted against the rules
and conventions of European music, feeling

3 The members of the Kouchka were Mous-
sorgsky, Rimsky-Korsakoff, Cesar Cui, BalakireS
and Borodin.

140

MEDH I N I \l I SI<

thai i lie 1 1 .ul n ional i lassii .1 1 music inhibited
the free expression oJ Russian musical
thought and feeling. Borodin did not leave
a greal numbei ol compositions; whal he
did leave has weight and commands re-
spect. Ii was the . 1 1 1 1 1 < >s 1 mi 1 .11 u li ins good
fortune foi yom speakei five years . 1 < > i<>
have rediscovered in Moscow i>\ sheer
happenstance Borodin's string sextet which
had been l<>si since its initial performance
i n I [eidell »ei g in 1 863.

I'hc third disciple ol I Iippoc rales de-
serving ol special tribute is lheodoi 1 > i 1 1
FOth ( 1829 94) (Figure .">). who was destined
to become one ol die outstanding leadeis
ol his cent in \ In the development ol both ol
the fields of medicine and music. Unlike
Helmholtz, whose musical contributions
Were direc ted mainh to sc ientific considera-
tions, oi to Borodin, the talented compose]
of music, Billroth w as both a physician and

Fie. I. Hermann von Helmholtz (1821-94).

VND ACADEMIA III

t ic 2. Mexaiulcr Porfirivich Borodin (1833-87).

a musician whose musical contributions
were mainly those ol a philosopher, edu-
cator, mentor and patron of the art.

Most physicians are well aware of Bill-
roth's contributions to the medical sci-
ences. His book on Surgical Pathology
(Allegcmci tic Chirurgische Pathologic mid
TIi era pic) is still regarded as one of the
finest treatises in medical literature, evi-
denced In the lac t that it has been trans-
lated into nine languages (and even into
Japanese). Of Billroth's boundless energy,
originality and foresight in surgery, every
surgical amphitheater in the world offers
ample proof. However, the fact that he
was a proved musician, that he wrote a
book on the physiology of music (Wcr 1st
Musikalish), that he exerted a dominant
influence on the music of his period — and

I V2

I. \\ II I.IAM SIM)! KM \\

I k.. .!. I heodoi Billroth (1829-94).

especially the music of Brahms — is less
well known, urn onh In physicians, bui
also by musicians. But, ihis is a fact. 4

Bn.i ROTH \M) Br \ll\ls

litis brings us lo the second area of
interesi . the music al 1 1 iendship bei ween
Billroth and Bi ahms.

During the earl) pan ol the last cen-
tury, two boys were born in northern
Germany about 125 miles apart. One boy
was born in 1SL'!I into a gracious, cultured
home on the enchanting island of Rugen
in the Baltic. He was the son ol a Lutheran
preacher and a descendant of four genera-
tions of distinguished scholars, artists and
musicians. The other boy was born four

4 Brahms composed three string quartets, two of
which he dedicated to Billroth. These quartets
are frequently played in my home. Upon reading
the dedication to Billroth on the title page of the
Opus 51 quartets, it is surprising how often ac-
complished musicians will ask, "Who was this
fellow, Billroth, anyway?"

years laici in 1833 into the uncultured
environment of the slum distiiei ol Ham-
burg. He was the son ol a pool, destitute '•
musician, and his family filled a compara-
tively lowly position in life. The first boy
became one of the world's greatest surgeons
whose surgical operations with minor
modifications are still used in almost every
hospital in the world; the second boy be- I
came one ol the world's greatest composers I
ol music whose music is heard in practi-
cally every concert hall. The fust boy's
name was Theodor Billroth; the second
boy's name was Johannes Brahms.

Theodor Billroth was gifted in music
lioin his early youth. His maternal grand-
parents had been professional opera sing- I
ers, and through them, he became familiar
with the compositions of the great masters. I
During his \outh, he- developed into an
excellent pianist. At the age ol nineteen,
at the recpiest of his family, Billroth gave
up the pursuit ol music as a career and
began the study of medicine at the Uni-
versity ol Goitingcn. Although he was a
student of medicine, nevertheless, at
Gdttingen he continued to keep up his
musical interesi and. on occasion, served 1
as the accompanist Eoi Jenny Lind and
other artists.

Compared to the early career of Bill-
roth, that of Brahms was epiite dissimilar. 1
In Brahms' early youth, two interested 1
music teachers recognized the highly <
gifted talents of Brahms and furthered his i
musical education, in spite of his lack of
facilities and financial support. He at-
tended grade school and educated himself |
for the most part by voracious reading f
and diligent study. As a means of liveli-
hood, he played dance music for the sail-
ors and their girl friends in the brothels
along the waterfronts of Hamburg. At the I
age of nineteen, he left Hamburg on a
concert tour as the piano accompanist to
the well-known Hungarian gypsy violinist.
Remenyi. In the course of this tour, he had

MEDICINE, MUSH Wli \c

Ml \

die good loiiune i eel Robert Schu

I mann, the composer, w ho proclaimed
Brahms io be ihc coming musical genius
ol Germany. Aftei concert izing extensiveh
lias a pianist, Brahms accepted the position
.in Directoi i>i the School ol Musi* in Det-
mold. Ii was while holding this posl thai
Brahms composed some ol his fines) cham
music.

1 am happy to have visited Detmold on
a number uf occasions, and while there, I
have alwa\s reserved Room 5 in the Hold
Stadt l i.inklui i where Brahms lived from
J 1857-55). Indeed. I hd a certain gratitude

that some ol m\ own ancestors eni.in.iied

t Ins i i( hl\ ( nil in ,,| area. When I v isil
I Detmold, ii also gives me pleasure to
wander along die path through the I euten-
berger Mountain to the Hermann monu-
" K '"i 'ii « t .s summit. Ii was along this path
dial Brahms is said to have obtained the
inspiralioii lor a numbei ol his most beauti-
' Eul melodies. In spile ol his prolific writings,
• ii no lime did Brahms evei pain a Iivine

I f 1 o

from the sale of musical compositions. He
I sustained himseli almosl entirely by con-
' ducting orchestras and < hoirs and Erom ap-
pearances as a concert pianist.

After his Detmold days, Brahms returned
to his home town ol I Eamburg and, deep
"i his heart, craved to be appointed the
conductor ol the Hamburg orchestra.
When this position, however, Eel] to an-
other, Brahms lefi Hamburg and settled
m Vienna, a city comfortably administered
by the Hapsburgs and glowing with the
warmth of musical tradition.

Several years prior to the time thai
Brahms removed to Vienna, Billroth had
accepted the professorship ol surgery at the
University of Zurich (1858). While at
Zurich, Billroth developed an aversion
for Wagner's music: however, the music ol
Brahms appealed to him. Thus, it was
with genuine' delighi thai Billroth met
Brahms, probably for the first time, in
Zurich when the latter was on a concert

I n,. I. Johannes Biahms ( IH.'i.'i ( I7).

tour. 5 I he accouni ol Brahms' reception

h\ Billroth is molded in one ol Brahms'
lei lei s to ( Mat a Schumann :

You ma\ he able l<> gathei how will I was received
from the fact that aftei m\ Inst concert in Zurich,.,
one ol two nmsii.il friends ... arranged a private
concert on Sunday.... They hired the orchestra
and telegraphed far and wide lor tin musical

scores \n\bod\ who had any interest in music

was invited to listen without further ado.

In 1867, when Billroth was offered the
Professorship ol Surgery at the University
"I Vienna, he readily accepted. The ac-
ceptance was probably made more gladly

since his friend Brahms had already ved

to Vienna the previous year. He and
Brahms had found much in common in
Vienna. Both were North German Protes-
tants transplanted to a foreign soil which
was predominantly Catholic, and both

A photograph of Brahms is shown in Figure 4.
Actually, Billroth and Brahms resembled each other
and were often mistaken for brothers.

1 1 1

I WILLIAM si \DI R.MAN

maintained .1 strong patriotism which the
war of helped to intensify. After

the Insi three months in Vienna, Billroth
wrote to one ol Ins friends that, within
two months, he had attended nineteen
concerts, had seldom gone to bed before
two o'clock in the morning, and thai he,
Brahms and Hanslick (the tnusit critii
who was also Professor of Music at the
University) had met several limes a week
to attend a concert, go to the theatre, or
simph to dine together. Billroth became
enraptured with the musical and .niisiu
life of Vienna, bm fell thai in science he
missed the strict German discipline to
which he had been accustomed. In Bill-
roth's words, "Science requires a firm and
hard ground rather than a rich, warm soil."

In Vienna, Billroth s home was simple
in design, with the exception ol the music
room, which was ornate. At the innumer-
able concerts given at his home, Bilhoth
was always the centei ol attraction. The
audience seemed to be inspired by his
striking image, his bncnanl spirit, his
glowing love of life, and his joy in making
music.

Practically all of the chamber music
composed by Brahms after 1867 was played
lor the first time before a selected audi-
ence in Billroth's home. Hanslick hu-
moroush remarked thai Billroth had "Jus
prirnac noctis." Throughout the ensuing
years, the new compositions of Brahms
were given to Billroth in manuscript form
for his comments. This was a flattering
acknowledgment of the confidence which
Brahms placed in Billroth's musical judg-
ment.

The evening activities in Billroth's home
were essentially of two types: those at
which string quartets and the leading
artists of Europe would perform informally
before a small group and those before a
larger group at which a formal concert
would be given and Brahms would con-
duct. The guests for these occasions were

proposed by Billroth, bin no invitations
were extended without Brahms' approval.
After the performance, there was no diffi-
culty in ascertaining Billroth's reaction. If
the artists performed creditably, cham-
pagne was served with the refreshments;
il the performance was mediocre, beer was
provided. (I hope a satisfactory libation
w ill be merited this evening.)

In the environment of Vienna and its
great university, Billroth and Brahms re-
mained loyal and devoted friends for more
than a quarter of a century. Although
Brahms held no academic appointment at
the University, he became closely affiliated
with it through his faculty associations and
his posts as conductor of various musical
organizations. The publication of 331
letters between Billroth and Brahms (many
ol which I have translated) a fiords an
excellent portrayal ol the cultured en-
vironmeni ol Vienna and gives an insight
into the dominant role that these men
pla\cd in the furtherance of music during
this past century.

With advancing years, Bilhoth became
the idol of the University and the Viennese
people. All hough Billroth (in a letter to
Brahms) expressed pleasure ovei his popu-
larity, nevertheless, in a more critical letter
to one of his former colleagues in Zurich,
he wrote, "What do the people really know
as to my scientific accomplishments? Noth-
ing. A myth develops: the myth starts
from something not understood, partly
horn superstition, and develops into a
miracle through the imagination of the
people. I believe that the surgical removal
of the larynx and replacing it with an arti-
ficial one G was the beginning of the myth
about me. The people have a morbid cu-
riosity and the press knows well how to
take advantage of it. Now, this would
all be very entertaining, but I am over-
whelmed by the profuse admiration. . . .

,; Billroth was a pioneering surgeon in inserting
artificial organs.

MEDICINE, MUSIC AND ACADEMIA

145

What I know, my students know also,
and perhaps even better. ... At my years,
I can be regarded only as a useful direc-
tion-pointer — one who can point to the
right way or at least in the direction to the
right way." It might be mentioned that
almost all of the chairs of surgery in the
leading medical colleges of Europe were
occupied by Billroth students.

The dominant passion throughout Bill-
roth's life was his love of music. He be-
lieved that the study of music greatly aided
his ability as a surgeon. Even in his medi-
cal writings, one senses the interest which
Billroth had in music and musicians. Thus,
in discussing methods for selecting men
who are best fitted for university pro-
fessorships, he quotes Schumann's maxim,
"Perhaps only the genius quite under-
stands the genius." One of the best illus-
trations of his tendency to write in musical
terms is a letter written to his old Profes-
sor Baum, at Gottingen: "The end of your
letter in which you speak about your age
in a sad tone does not agree with your
otherwise youthful attitude. . . . The inspi-
ration of living lies in the beautiful har-
monic sequence of our major and minor
thoughts. You have still plenty of time to
think of the closing symphony of life as
it is portrayed by Beethoven in the end of
"Egmont" and in the "Ode to Joy" in
Beethoven's Ninth Symphony. May God
still keep you long as a conductor of the
orchestra and have patience with one of
the oldest members in your orchestra who
is a violinist and is anxious to be ad-
vanced to the first stand."

At Billroth's death, the entire city of
Vienna went into mourning. No ruling
monarch was ever accorded more reverend
respect. Brahms commented that, among
the enormous crowd in attendance at
the funeral, there was not one indifferent
or inquisitive face but only expressions of
deepest sympathy and affection. The stature
of Billroth, the physician and musician,

perhaps can best be appreciated by quoting
a brief portion of the lengthy eulogy
given by the rector of the University:

For Thcodor Billroth, the black flag of mourning
is flying from the roofs of official buildings. It sig-
nifies the death of a man who was the foremost
ornament of our faculty. Science has lost one of its
most genial representatives, an inspiring spirit at
whom all of us younger men gazed in venera-
tion. . . . The Vienna Medical School, all of Austria,
and all of the world mourns this irreplaceable
loss. . . . When he refused the call to the professor-
ship of surgery in Berlin, he received from us an
ovation which was a storm of enthusiam and love.
His words on that occasion still ring in our ears,
when he said, 'I cannot conceive that I would
ever say farewell to Vienna.' Now, we shall have-
to accustom ourselves to the thought that we have
lost forever this scholar, this musician, this Sa-
maritan, this thinker, this poet, and in one word,
this genius — Thcodor Billroth.

Academic Festival Overture

In endeavoring to capture the unique
spirit of commencement time at the
European universities during the past cen-
tury, attention has been directed to the
University of Vienna in which Billroth,
Brahms and Hanslick (the Professor of
Music) dominated the medical and musical
disciplines. It seems to me that this spirit is
fittingly expressed in the music of Brahms'
Academic Festival Overture, parts of which
I should like to play for you. The Aca-
demic Festival Overture is mentioned in
at least one of the letters of Brahms to
Billroth, and it can be inferred that
Brahms discussed the material and con-
struction of this work with his devoted
friend, Billroth.

The overture was written in 1880 by
Brahms as a gesture of thanks to the
University of Breslau upon the conferment
of an honorary doctorate degree. Thus, we
see that this quid pro quo for honors was
effectively applied in university dealings
even a hundred years ago. In composing
the overture, Brahms did not make the
customary formal approach, but based it

14G

Melodie des Landesvaters
-k-

Was kommt dort von der hoh (Fuohslied)

rr~f — f~f1

H

5-

1 — 1

1—

Fic. 5. Songs incorporated in Brahms' Academic Festival Overture.

upon the point of view of student tradi-
tion. The work involves the music of
four time-honored student songs which,
with the exception of one, were joyously
sung at graduation and other festive oc-
casions.

The first song in the overture, which is
brilliantly intoned by the trumpets, bears
the title, "Wir hatten gebauet ein statt-
liches Haus" ("We Had Built a Stately
House") (Figure 5). It is said that some of
the student parodies were slightly ribald
and would suggest that at least some of the
houses that were built were not always in
the character of stately mansions. The
translation of the first verse is as follows:

We had built a stately house,

Inside of which we placed our trust in God,

In spite of weather, storm, and fear.

The second student song is the "Landes-
vater" (the most solemn song to the
Father of the Country). 7

The "Landesvater" song (Figure 5) was
written before 1770 and was used on rare
occasions of patriotic consecration. A
sword was passed around among the stu-
dents in a fraternity and each student
pierced the sword through his colored
fraternity cap, singing, "Ich durchbohr den
Hut und schwore, halten will ich stets auf
Ehre, stets ein braver Bursche sein." ("I

7 The full text of this song was obtained through
the kindness of one of my friends who is a pro-
fessor at the University of Heidelberg. I might say,
parenthetically, that in preparing the material for
this talk, I am in the position of Charles Lamb
who explained how he wrote one of his essays.
Said he, "I milked twenty cows to get the milk,
but the butter I churned is all my own".

Ml- 1 HUNK. Ml'MC AM) \( Ml \

147

pierce the hat and swear I will always
insist upon honor and always be a brave
fellow.") After the ceremony, the stu-
dent's sweetheart was honored with the
task of closing the hole in the hat by
embroidering a silver oak leaf over it as a
token of participation in a Landesvaler.

The third song is the "Fuchslied" (Fig-
ure 5) which literally translated is "Fox
Song." A "fox" in the German universities
is an uninitiated freshman fraternity man.
The song is a rollicking, jolly roundelay
used in freshman initiation ceremonies.
In the ceremony, the freshman entered the
room riding on a heavy leather upholstered
chair. The rumbling rhythm of this ride
is well-marked in the instrumentation.

The melodies of these three songs are
interwoven in the first part of the over-
ture. In using folk music, a composer can-
not move abruptly from one song into
the next but must employ bridgings.

(At this time, a tape-recording of that por-
tion of the overture was played which con-
tains the three songs.)

The closing, or fourth, student song
is the well-known "Gaudeamas Igitnr"
("Now Let Us Be Joyful"). This was and
remains the official anthem of the German
university student.

In composing the Academic Festival
Overture, Brahms played the first three
songs against each other in a most delight-
ful way, and after a recapitulation of all
of the material, he had the orchestra
burst into a highly-spirited jovial version
of the celebrated "Gaudeamus Igitur" in
which the students joined wholeheartedly
in the singing. The translation of the
fourth verse of "Gaudeamus Igitur" is as
follows:

Raise we, then, the joyous shout:

Life to Alma Mater!

Raise we, then, the joyous shout:

Life to Alma Mater!

Life to each professor here,

Life to all our comrades dear,

May they leave us never,

May they leave us never.

Brahms liked to refer to the Academic
Fesitival Overture as his "laughing" or
"happy" overture. He was criticized for
pitching the "Gaudeamus Igitur" too
high. This song is usually sung in either
the keys of A- or B-flat. In order to achieve
brilliance, Brahms raised the pitch to the
key of C. So, excepting for the sopranos
and tenors, one may find the orchestral
version a little high for singing.

For the Academic Festival Overture,
Brahms employed the largest orchestra he
had ever used in any of his compositions.
At the end of the overture, he has every
player scraping, blowing and hitting as
hard as he can. Although the intensity of
the sound on the recording is reduced,
nevertheless, many may complain that the
rendition is too loud. All that can be said
in reply is that it is not as loud as it was
intended to be.

(The Philadelphia Physicians String Quar-
tet played a transcription of each of the four
songs. A tape-recording of the closing sec-
tion of the overture was also played.)

The story of the Academic Festival Over-
ture could be written entirely around
Brahms. However, how much of the com-
position is really Brahms, and how much
of it is Billroth? Certainly the happy festive
character of the piece is more in keeping
with the genial, extroverted personality
of Billroth. Moreover, Brahms never at-
tended a university as an undergraduate
student and obviously had never taken part
in a student fraternity initiation or in a
Landesvater ceremony. Therefore, the stu-
dent songs that were incorporated into the
overture would not have been as meaning-
ful to Brahms as to Billroth, who had
spent his entire life amid academic sur-
roundings.

It is a matter of record that Brahms
discussed the composition with Billroth,
and undoubtedly, there was an exchange of
ideas concerning it. The exchange of ideas
and the mingling of men's thoughts are
ennobling forces that enrich the intellec-

148

F. WILLIAM SUNDERMAN

tual aura of every college or university
environment. This exchange provides the
inspiration for research and creative en-
deavor, and as a consequence, it oftimes
becomes difficult (and really unnecessary)
to give appropriate credit. However, the
question might reasonably pose itself into
an inquiring mind: Does the Academic
Festival Overture emanate mostly from
Brahms or mostly from Billroth? And then
the second question should be asked:
Does it really matter?

The names of Helmholtz, Borodin, Bill-

roth and Brahms and their monumental
works will doubtless live through the
ages. The last movement of Brahms' Ger-
man Requiem was based upon a verse
from Revelations which the Pastor also
used as the text at Brahms' funeral and
which I quote:

Blessed are the dead which die in the Lord for
henceforth they may rest from their labors and
their works will follow them. (Rev. 14:13)

I feel certain that the traditions of our
College of Physicians encompass this
thought.

Distillates from Hieronymus Brunschwig's
Book of Distillation

By MARION B. SAVIN, m.s., and HAROLD J. ABRAHAMS, ph.d.i

THE closing years of the fifteenth cen-
tury found Hieronymus Brunschwig
(1440-ca. 1512), surgeon of the Im-
perial Free City of Strassburg, writing his
second book: Liber de arte distillandi de simplici-
bus. Das Buch der rechten Kunst zu distiliren die
eintzigen Ding. It was published in Strassburg,
as of May 8, 1500, by the famous house of
Johannes Griininger, which had, three years
earlier, brought out Brunschwig's first:
Buch der Cirurgia. That historians of chemistry
have, for a long time, shown a deep interest
in and respect for this work (known as the
Small Book of Distillation, or Kleines Distil-
lierbuch) is quite understandable, in the light
of the fact that, in an era when alchemy was
still bogged down in its non-productive
absorption in gold-making, with its literature
virtually incomprehensible except to its
illuminati, the Distillierbuch proved to be a
practical work upon distillation, written in
language (Middle German) quite under-
standable to the ordinary citizen of the time,
for whose use it was intended by the author.
For this reason, Brunschwig's Book of Distilla-
tion, one of the early printed books devoted to
the practical phase of alchemy, and one of
the earliest on applied chemistry written in
German, has become a bridge which enables
us to make the transition from alchemy to
chemistry, along with such other published
works as Agricola's De Re Metallica (1556)
and Libavius' Alchymia (1595).

The Book of Distillation consists of three
divisions: the first is devoted to the various
forms of apparatus for distillation — furnaces,

1 Dr. Abrahams is Research Associate, Library of
The College of Physicians of Philadelphia, 19 South
22nd Street, Philadelphia, Pennsylvania 19103.

This paper is part of a lengthy work supported by
a grant from the American Philosophical Society.

stills, condensers, receivers, various sources of
heat (i.e., from fermenting horse-dung, ant-
hills, souring dough, sun's rays), and so on,
thus providing a full account of the art of
distillation; the second deals with the descrip-
tion of the medicinal plants which are to be
subjected to the process of distillation; the
third division gives the uses of these distillates
(or "waters," as they are called) in the treat-
ment of the ills of man's flesh. The book's
three divisions are illustrated by the use of
charming woodcuts, making this work the
earliest attempt at so depicting chemical
apparatus and chemical manipulations. The
result is a practical work upon distillation and
its applications. Many editions and various
revisions appeared during the century which
followed, a major one being Liber de arte
distillandi de compositis (1512), the so-called
Grosses Distillierbuch, or Large Book of Distilla-
tion (1). It needs to be added that the Book
of Distillation is of interest not alone to his-
torians of chemistry. Historians of botany,
medicine, pharmacy, interior design, the art
of woodcuts and social historians will find
much to interest them in this work.

The fact that a surgeon would concern
himself with the preparation of medicines
seems to require an explanation. In his time,
the physician was a university graduate,
devoted to the ideas of the medical authorities
of olden times. The ills which required treat-
ment with scalpel or other instruments were
left to the barber-surgeon, as being beneath
the dignity of treatment by the physician.
Surgeons often became city-poor doctors,
and thus treated great numbers of patients,
who could not afford to pay the large fees of
doctors, nor purchase the costly medicines of
the pharmacists. Surgeons developed a
progressive attitude to the enlarging of their

149

150

MARION B. SAVIN AND HAROLD J. ABRAHAMS

knowledge, fostered by their wide professional
experience, and learned to ignore the hide-
bound theories of contemporary physicians,
who refused to abandon their veneration of
Greek and Arab texts. For surgeons, it was
only a short step from soiling their hands in
the treatment of human flesh to soiling their
hands in experimenting with the materials
and methods of manufacture of medicinal
preparations. Thus, surgeons became distillers
of medicinals, basing their high regard for
the process of distillation upon the widely
held belief that by this process the very soul
of an herb could be parted from the coarse
"gross") diluent, be captured in the dis-
tillate, and be made to render a far more
potent medicinal account of itself than could
the crude, undistilled drug. The time of
Paracelsus and the iatrochemists was near at
hand, and the sixteenth century brought vast
changes, one being the application of chemi-
cal principles to pharmacy and medicine.
The latter disciplines spurred further develop-
ments in chemistry in a reciprocal fashion.
Paracelsus was friendly to the idea of separat-
ing the active medicinal principles from the

gross matter of herbs and drew inspiration
from the work of the group of surgeons, of
which Brunschwig was the leader. (It is
therefore necessary to take into account the
work of the Strassburg surgeon in the domain
of chemistry, if we are to make a true assess-
ment of Paracelsus and iatrochemical in-
fluences.)

As to Brunschwig's distillation products
(or "waters," as he called them), they may
furnish us with many reasons to smile toler-
andy, or even chuckle, the while that we
remember, on the other hand, the many
virtues of his contribution. Was it humor,
informed by deep wisdom and understand-
ing, which led him to observe that persons
suffering from melancholia would profit from
engaging in distillation activities, because the
hot, moist atmosphere attendant upon such
work would be beneficial to those having a
"cold, dry complexion," which was the root
of this malaise? (Our modern equivalent
might be the steam bath.)

The purpose of the present paper, with its
excerpts from The vertuose boke of the distyl-
lacyon of all maner of waters of the herbes . . .

HIERONYMUS BRUNSCHWIG'S BOOK OF DISTILLATION

151

translated] into Englysshe out of Due he by Lau-
rence Andrew, London, ca. 1530, is to supply
an opportunity to smile a little, sometimes
with Brunschwig, sometimes at him, as we
try to obtain a better understanding and a
more complete picture of a fifteenth century
mind.

(Note to the reader: Laurence Andrew, Brunschwig's
English translator, followed the practice of indicating
an abbreviation by placing a bar or line above a
letter which precedes the omitted letter, viz., co-
plexios for complexions. The letters u, y and i of
those times are now v, i, and j, respectively.)

I

Brunschwig ascribes great importance to
the color of his raw material :

Chapter CLX Water of Capones (capons) :
[160] "Capo in latyn. The best parte and tyme
of hys dystyllacyon is ye shall take a blacke
capon fourc or fyue yere olde/and worowe and
pluck hym without wettynge of water/therafter
cut hym in foure quarters and put away all the
grece fro hym/and wasshe well and make
clene the entrayles/and then choppe hym in
small peces/and dystyll hym than per Alem-
bicum/or in a helmet lyke other waters . . . The
same water dronke in the mornig/at none/and
at nyght . . . coforteth and strengtheneth the
nature of the body . . . and reioyseth the spy-
ryte . . . cawseth appetyte to eate meate . . . and
wythdryueth all dysseases frome the harte +
stregtheth a persone so moch that it is sene on
hys body. In the mornyng and at nyght the
face wasshed wyth the same water and lette
drye agayne by hym selfe causeth the face to be
fayrc and clene."

Nor was a black hen any safer, if it strayed
within reach of the Brunschwig distillatory:

Chapter CXXXI Water of hennes (hens)
[131] "Gallina in latyn . . . worowe a good blacke
henne . . . Tha put of all feders . . . and distil
the same in an helmet. After that put the water
in a glasse and dystyll it per balneum marie.
Water of hennes shall be gyuen to drynke to
them whych haue ben so longe seke/that he is
hole consumed and is hole feble and faynte/it
is good aboue mesure for such one/for it gyueth
hym so moche vertue + strengtheth hym so
moche/that al the medecyns haue mcruayll of
the same."

Nor were black calves any safer:

Chapter CLIIII Water of calves blodc
[154] "Sanguis vituli in latyn. The best parte and
tyme of hys dystyllacyon is/the bloode of a black
calfe/and the blacker the better . . . [the distil-
late] warmeth + confortcth the membres
greued with the Palscy/rubbed with the same
water in the mornyng 4- at nyght well warinc
and clothes wet therein and warmc layde there-
upon. The same water confortcth the membres +
senewes ..."

Chapter CLV Water of Calfes blode and longues
to gyddrc

[155] "Sanguis + pulmo vituli in latyn. The
best parte of his dystyllacyon is/the blode 4-
longues of a blacke calfe chopped to gyder +
dystylled per Alebicu . . . good for consumynge
membres/the membres rubbed therwith and
let drye agayn by hym selfe/but yf the body
consumeth than the same water must be dronke

Half a loaf is better than none:

Chapter CLVI Water of Calfes Lyuer
[156] "The beste lyuer for to dystyll is of a blacke
calfe wha it can be gotten . . .

Chapter CCVII Water of Oxce blode
[207] Sanguis bouinus in latyn. The best parte
and tyme is of a black oxe which goth in a good
pasture where as many flowres do growe/
dystylled in the May." [good against paralysis
and gout]

Chapter CCXXII Water of the gall of an oxe
[222] "Fel tauri in latyn. The best gall is of a
blacke oxe/whan they may be goten/and it
shall be dystylled in July /or in the canyculer
dayes.

Of the same water an houre before night in
the iye doth withdryue the fleces and spottes
in the iye. The same water is good agaynst the
worme in the fynger/clowtes wette therin +
layd theron twyse or thryse contynuynge/and
at eche tyme wet agayne . . . than the worme
dyeth."

Chapter CCXLII Water of blacke Cheryes
[242] "Cerasa nigra in latyn . . . The best parte
of the dystyllacyon of the great blacke cheryes is/
the moste blackest that may be goten + dys-
tylled ..." [good against dropsy, palsy, swell-
ings, Iaske]

Geriatricians, please note !

Chapter CCC Water of the herbe of pelether
[300] "Herba helebori nigri ... I haue sene a

152

MARION B. SAVIN AND HAROLD J. ABRAHAMS

man at Stracsborowe whiche was a hondred and
thyrty ycre oldc whych had euery day without
upon his hade the powder of the same herbe/the
quantyte of an hazel nutte + lycked therof/and
he abode in good helthe unto the tyme of
hys naturall endynge of lyfe."

II

In which the author of the Book of Distilla-
tion reveals his failure entirely to emancipate
himself from alchemy's acceptance of astrol-
ogy and superstition:

Chapter CLVI I Water of creuys

[157] "Cancer in latyn/the beste parte + tyme
of hys dystyllacyon is the quycke creuyces whan
the mone is at full/stamped and dystyllcd
. . ." [for palsy, burns]

Chapter CCXII Water of pechc leues
[212] "Folis persicorum in latyn . . . The best
parte and tyme of theyr dystyllacyon is/the
leues stropped of in the cressynge of the mone/
whan she is almoste full/dystylled in the ende
of the may."

Chapter CCXLV Water of saynt Johnswortc
[245] "Scopia regia/yperycon vel herba sancti
Johannis vel herba perforata in latyne . . . Muri
domus consperci cu aqua ista/valet contra
diabolicam illusionem . . ." [when the walls of
the house are sprinkled with this water it is
effective against diabolical illusion]

Chapter CCXXX Water of Rue or herbe of
grace

[230] "Ruta in latyn . . . who so hathe the same
water in his howse can nat be hurte of the deuyll
by the grace of god . . ."

Ill

Chapter CLXVIII Water of moderworte
[168] "Citraria vel Melissa in latyn ... Of the
same water dronke a spone full fastynge/
causeth in a man to haue sharpe wytte/good
understandynge/and good memory and re-
mebraunce/for to kepe and remembre euery
thynge that is possyble for a man to remembre
. . . The same water dronke an ounce and a
halfe/causeth them to be mery and refressht
agayn/which were afore sore greued with
anger /it maketh also softe and good myndes/
and an amyable colour . . . The same water
preserueth a man from gray heres/twyse dronke
of the same water in a day . . . and the heres
wet with the same water/and let drye agayn
by hym selfe . . . The same water is very good
for hym whose tonge is greued with such sekenes

nat of nature/that he can not speke/hc shall
take a blew wollen clothe wet in the same
water/and the tongue often wasshed thcrwith
and than it shall become hole agayne/and the
spechc also."

Chapter: — "A fayre addycyon of an other
master of the vertue of aqua vitc . . ."

(first citation)

". . . Aqua vite . . . gyueth also yonge corage
in a person/and causeth hym to haue a good
memory and remembraunce. It puryfyeth the
fyue wyttes of melancoly + of all unclennes
whan it is dronke by reason + measure. That
is to understandc fyue or syx droppes in the
mornyng fastyng with a sponefull of wyne/
usyng the same in the maner aforsayde the yll
humours can nat hurt the body/for it with-
dryueth them out of the vaynes . . ."

Chapter XCI Of fenell herbe water
[91] "Feniculus in latyn . . . Of the same water
dronke amonge/at eche tyme an ounce 4- the
drynke myxced therewith wythdryueth and
taketh away the lechery."

Chapter CIX The water of the yellow vyolettes
[109] ". . . Of the same water dronke in the
mornynge and at nyghte at eche tyme an ounce/
is good for them that haue loste theyre wyttes

Dronke of the same water/at eche tyme an
ounce and a halfe/thre or foure wekes con-
tynuynge/cawseth the women to be fruytfull
... In the mornynge 4- at nyght dronke of the
same water at eche tyme an ounce 4- a halfe
contynuynge vii or viii dayes is good for men or
women which euer be besy in worke of genera-
cyon . . . the same water sharpeneth the wyttes
4- understandynge . . . the same water . . . re-
ioyseth and cawseth to be mery the harte and
mynde of a man . . . and it warmeth the mary
in the bones and dryeth oute the colde blode."

Chapter LIX Water of Cardo benedictus

(first citation)

[59] "Cardo benedyctus in latyn . . . The same
water dronke in the same mesure is good against
the payn comynge in the hed aboue the eye/
named Epicranea/that is wha a body thynketh
that a nayle is beten thrughe his hede.

The same water . . . cawseth good memory/
and conforteth the remembraunce."

Domestic tranquility:

Chapter LXVI Water of valerian
[66] "... A man and a wyfe maryed to gyder
and can not well agre to gydre/them shall be
gyuen to drynke of the same out of one vessell
or pot and they shall agree."

HIERONYMUS BRUNSCHWIGS BOOK OF DISTILLATION

153

Further notes on memory:

Chapter LXXIX Water of Veronica

(Jirst citation)

[79] ". . . dronke of the same water is pryncy-
paJly good abouc all waters for the memory
and remembraunce/whS the hede is enoyntcd
therwith outwardc/and let drye by hym selfe
agayne bycawsc it confortcth the hede and
braynes/and lyghtcth the tongue/and clenseth
the blode."

And again!

Chapter CLXXII Water of Maryolayn
[172J ". . . Samsucus in latyn . . . dronke of the
same water . . . and the hede enoyntcd ther-
with/causeth a good rcmembraunce and
memory . . ."

On mental and physical hygiene:

Chapter LXXIII Water of straw beryes

{first citation)

[73] "Frage in latyn ... It is good for them
whose nature mountcth upwardc in the face
and the face becometh red/yf the face be wasshed
therwith/it vanyssheth awaye . . .

The mouthe often wasshed with the same
water/is good agaynst a stynkyngc mouthe . . ."

Silence is golden (Returning to Veronica) :

[79] ". . . In lykewyse synketh the great anger +
upblowynge of the longue/whan a dragma of
the powder of the same drye herbe veronica is
myxed wyth the same water of the Veronica/
and so dronke/bycawsc of no membre cometh
so moche payn and woo as fromc the longue/for
whan the membres be in reste and quyetre/than
the longue is euer rysynge up and labourynge/
whether a person be slepynge or watchynge/
euer is the longue labouryng with blowynge
and unclenes/. . . The wynd is come all orygy-
nally from the longues. Therfore it is a very
wyse man whyche that can refrayne the tongue
and the longue."

Chapter CCIII Buglossa

[203] ". . . In lykewyse I my selfe haue sene in
the towne of Couelence in Almayne a scole
mayster which had studyed so moche that he
had loste his wyttes. Than came there an un-
lerned Empyricus and dyde gyue hym to drynke
of the same water /and chopped the herbe
for his meate/and the herbe stamped/he dyd
laye unto hys hede plaster wyse/thre or foure
wekes contynuynge/wherwith he became fully
hole and well amended/and gate his wyttes

agayn/and he studyed moche more than he
dyd before

. . . dronke [thrice daily] an ounce and a halfc +
his wync myxced therwith causeth good un-
derstandynge + memoryc

For the perfect host:

... It is saydc also yf a great company were
syttynge at dyner or soupper/and were spryn-
kled with the same water /it sholdc cause them
all to be mcry . . ."

Courage !

Chapter CCXXVI Water of Rosemary

{first citation)

[226] "Ros marinus in latyn . . . dronke of the
same water/at eche tyme two ouces/cawseth a
man to be courageus for it confortcth the sub-
stance of the harte/and it is also good agaynste
the wofull payne of the harte."

Chapter CCLXXV Water of Wormewode
[275] "Absinthium in latyn. . . The same water
hath ryght merueylous great vertues/for it is
said of dyuers persons/that the iuce or water of
the same herbe hath be gyuen for a token in
maner of incantacyon unto great captayns or
conductours of an hoste or armey/beleuynge
that thrugh suche a token/they sholde haue
vyctorye agaynste theyr enemyes but how it
shold be occupyed/I can nat tell

. . . Put of the same water in ynke that ye
wyii wryte with/and the bokes that be wrytcn
thcrwith/shall be preserucd from the eatynge
of the myce."

IV

For the bald set:

Chapter: — ■ -

"A fayre addycyon of an other master of the
vertue of aqua vite. . ." {second citation)

"Aqua vite . . . whan it is dronke and the hede
enoynted therwith the space of xx dayes/it
heleth alopiciam/or wha it is dronke fastynge with
a lytell tryacle It causeth the here to grow well +
kylleth the lyce and flees . . ."

Chapter CXXI Of Hony water

[121] "Mel in latyn . . . The hede ofte wasshed +

rubbed therwith causeth to grow fayrc + loge

heres."

Chapter CCXXVI Water of Rosemary
[226J . . . "The hede wasshed with the same
water/and lette drye agayne by hym selfe/
preserueth the fallynge out of the heres +
cawseth more for to growe."

154

MARION B. SAVIN AND HAROLD J. ABRAHAMS

Chapter CCIX Water of percely

[209] "Petrociliurn in latyn. . . Any place that is
enoynted with the same shall waxe balde/and
it takes away the heres of the same place."

V

Tall tales department:

Chapter: "A fayre addycyon. . ." Brome flowre
water.

". . . whoso drynketh in the mornynge ii or
iii ouces is preserued from the thyrst all that
dayc."

Chapter LXV Water of Fumytory
[65] "Fumus terre in latyn. . . Drok of the same
in the mornynge + at nyght at eche tyme two
ouces/four or fyue wekes cotynuynge is good for
euyll fauoured faces 4- maketh them fayr +
pale of colour."

Chapter LIX [Cardo benedictus again]

{second citation)

[59] ". . . It happened upon a tyme that a man
was slepyng under a tree + a snake of an ell
longe was crept in his throt + to hym was gyue
fyue or syx droppes of the same water /and anone
the snake came out agayn 4- dyed."

For broken bones:

Chapter LXIIII Water of centory
[64] "Centaurea in latyn . . . whan one hath
broken a bone in his body than he shall drynke
of the same water luke warme in the mornynge +
at nyght at eche tyme an ounce for it heleth 4-
consolydeth toged agayn."

Chapter LXIII Water of straw beryes [again]

(second citation)

[73] ". . . The same dronk in the mornlge +
at nyght is good for them that hathe broken a
bone or a legge."

Jungle medicine:

Chapter LXXIX Veronica [again]

(third citation)

[79] ". . . It is redde of a lytel venymous worme
smaller than a Scorpyon/whyche kylleth the
yonges of the lyon with his venymous stynges.
And whan the lyon perceyueth it/then he
choweth of the same herbe/and layth it upon
the venymous swellynge of his yoges/than it shal
be no harme to the but they shall become hole
agayne/

Also it is redde of a bere/wha he is to fatte/
tha he eateth of y same herbe/wha he can get
it/ + therwith he becometh lene and well
dysposed and bolde/lykewyse the bere when he

hath sene great oxcen/than he desyreth to haue
and to eate the fattest of them/but yet he is
afrayde. But as sone as he hath eaten of the same
herbe/than he becometh bolde and taketh the
fattest oxe without feare/

It is redde of the bere/whan he is seke than he
eateth pysmer/4- tha he becometh hole and
eased/and after that he eateth so moche of them
that he can not dygest them in his nature/than
he falleth somtyme in swowne and fayntnes.
Than he eateth of the herbe Veronica/ 4- thereof
he getteth the laskc + therof he become agayn
hole. It is redde that the garye water snakes
engendreth them with the ealc/a fysshe called
Anguilla in latyn. And whan the eale hath
coceyued/tha she becometh so colde of the
venymous nature of the snayle that she can not
suffre the water no longer /and than she crepeth
often out of the water and seketh the same herbe/
and eateth it + than the yonges must nedes
departe from her/and dye before or they be
warped. And yf it be that the eale can not fynde
the same herbe/than the yonges kyll her or they
be warped ..."

Chapter CLXIX Water of May or parke floures
[169] "Lilium conuallium in latyn. . . The same
is good for any body that is hurt or harmed by
styngynge of any venymous beste or other
worme/as a spynner/or suche lyke . . . What
maner of persone that is stynged with a bee/or a
waspe/or with other stynges/he shall laye a
cloute wet in the same water therupon in the
mornyge + at nyght . . .

In the mornynge and at nyght dronke of the
same water/. . . and the hede therwith enoynted/
conforteth the braynes/and strengtheth the
mynde or the wyttes . . .

With the same water often the tongue
enoynted/causeth one to come to his speche
agayne. . ."

Rosemary once more:

Chapter CCXXVI (third citation)

[226] ". . . In the forsayd maner dronke of the
same water/sharpeneth the tongue and cawseth
well to speke. And no body can tell the myght
and vertue of the same water.

. . . the face wasshed with the same water/
causeth a fayre and clere face.

. . . The same water cawseth a body to appere
longe tyme fayre and yong/whan it is dayly
used/myeced with his drynke a lytell/and
outwarde therwith rubbed.

... It causeth the wome to be frutful wha
they make a bath of his decoccio/the same bath
is also a bathe of lyfe/a restraynynge + a with-

HIERONYMUS BRUNSCHWIGS BOOK OF DISTILLATION

155

drawyng of agc/a rcnewyng of a body/for it Chapter Line

hath many secret vertucs . . ."

„ . 3

Chapter CCXLVIII Water of corona regia ^

[248] ". . . The same water is good for them that 2

hauc euyl hasty moued wyttcs/cloutcs wet ^

therin + bounde upon the hedc. The same water

shall be dronk of noble prynces and gouernurs of

lodes + regyons that sholdc be wysely

goucrned + of all them that wolde goucrne

themselfe by wysdom."

For the ladies:

65 2
4

Chapter LXXIX Water of Veronica

(fourth citation)

[79] ". . . In the mornynge fastynge dronke two
ounces of the same water v or vi wekes con- 73
tynuynge/causcth a body to become lene of 2
flesshe . . .

The same water with the powder dronke in the
maner aforsayd is good for women that be fatte
and wolde fayne bcre chylde + be lene/bycause
she myght the better conceyue/for it dysposeth 2
the women to conccyuc. And lykewysc as fyre 79
purgeth the golde/so purifyeth the same water 3
the wome for to conceyue a chylde." 3

Chapter CLXVII Water of Lauendre
[167] "Lauendula in latyn ... A nutte shell full
of the same water myxced with other water/
wherof is made dowgh/so what brede is bake of
the same dowgh shall nat waxe moldy."

Annotations 2

Note to the reader: To facilitate the use of the follow-
ing annotations, the Roman numeral designations
of the text have been replaced here by Arabic nu-
merals and the citations placed in numerical order,
rather than preserving the order in which the cited
passages appear in the text of the present paper.

Where any chapter is drawn upon more than
once, the citations are designated as "first," "second,"
and so on.

Chapter Line

59 (first citation)

4 eye — eyes

4 a nayle is beten — a nail is beaten,
(a rather effective description!)

2 Sources :

1 . The Oxford English Dictionary. Edited by James
A. H. Murray, Henry Bradley, W. A. Craigie, C. T.
Onions, Oxford, 1933.

2. Anglo-Saxon Dictionary. Bosworth and Toller,
London, 1954.

3. The Century Dictionary and Cyclopedia. William
Dwight Whitney, Ed., New York, 1895.

(second citation)
ell — forty-five inches
gyue— give
whan — when
toged — together

fumytory — common name for a
species of the genus Fumaria
(from Latin-fumus terrae, "smoke
of the earth," so named because
of its odor)
drok — (dronk), drunk
euyll fauored faces — evil-favored
faces. (If Brunschwig merely
meant acne this might not be a
very tall tale.)

(first citation)
whose nature mounteth upwarde
in the face and the face be-
cometh red — a surge of emo-
tion^)

(second citation)
mor ni ge — morni ng

(first citation)

wha — when
hede — head

(third citation)

lytel — little
yoges — young
the — them

redde of a bere/wha he is to fatte —
read about a bear that when he
is too fat
9 lene — lean
10 sene — seen

1 5 seke — sick

1 6 pysmer — ants

19 laske — loose bowels

20 garye — misprint for gray?

21 engendreth — beget or propagate

22 - coceyued — conceived

27 warped — the young brought forth
prematurely

Note: The eel and the snake, being members of
different classes of vertebrates, could hardly mate
or beget offspring. Though the eel has gills it can
scarcely be likened to a snail, and the failure to "suffrc
the water" is rather reminiscent of an amphibian
which has undergone metamorphosis, during which
the gills are absorbed and air-breathing lungs have
developed. One cannot but wonder whether Brunsch-
wig's source has mistaken some sort of salamander
(an elongated amphibian) for the eel (a fish). The
reference to the killing of the eel by its young, if
they cannot leave the mother's body, is a great
misunderstanding of the reproduction of the eel.

156

MARION B. SAVIN AND HAROLD J. ABRAHAMS

It may be that the eel (or salamander) was filled

Chapter

Line

with

parasitic

worms, which were mistaken for

3

crcssynge of the mone — waxing of

young eels.

the moon

222

4

canyculer days — canicular days

Chapter Line

(dog-days), a certain number of

(fourth citation)

days before and after the heliacal

8

fyre — fire

rising of the dog-star

109

5

thre — three

5

iye — eyes

12

mary — marrow

7

worme in the fynger — ringworm(?)

121

2

ofte — often

226

( first citation)

4

loge — long

3

ouces — ounces

131

3

tha — then

(third citation)

3

of— off

3

And no body can tell the myght

3

helmet — a type of distillation

and vertue of the same water —

apparatus very commonly used

This belief was held as early as

by Brunschwig, in which a cone-

Avicenna, and perhaps even

shaped head was fitted to the

earlier. It is a specimen of the

lower part of the still.

extravagant trust which was

131

5

balneum marie — water-bath

placed in certain herbs from

9

medecyns — physicians

time immemorial (and con-

9

meruayll — astonishment

tinues to be, by some persons).

154

5

greued — troubled

10

wome — women

6

clothes — cloths

11

decoccio — decoction

155

1

to gyddre, (to gyder) — together

230

3

deuyll — devil

4

per Alebicu — per Alembicum, i.e.,

245

3

cu — cum

in an alembic

5

diabolicam illusionem — exactly

6

than — then

what a diabolical illusion is,

156

I

lyuer — liver

presents a difficulty.

3

wha — when

248

2

euyl hasty moucd wyttes — vicious

157

1

creuys — crawfish

temper (?)

3

mone — moon

4

gouernurs — governors

160

4

worowe — strangle

5

15des — (londes), lands

6

grece — grease

275

2

merueylous — marvelous

6

fro — from

3

dyuers — divers

6

clene — clean

3

iuce — juice

7

peccs — pieces

4

token — a pledge of authenticity

9

coforteth — comforts

6

beleuynge — believing

10

reioyseth — rejoices

7

occupyed — used

167

1

lauendre — lavender

9

ynke — ink

3

dowgh — dough

10

bokes — books

4

bake — baked

11

myce — mice

4

waxe — become

300

4

hade — hand

168

4

remebraunce — remembrance

9

heres — hairs

Chapt

er called "A fayre addycyon of another

12

sekenes — sickness

master of the vertue of aqua vite ..."

12

nat — not

(This

section appears at the end of Brunschwig's

12

speke — speak

book, and the implication is that it was written by

13

blew — blue

another person.)

14

than — then

(first citation)

14

hole — whole, (well)

Line 2

aqua vite — distilled

169

1

water of May or parke floures —

spirits; brandy

lily of the valley(?)

3

gyueth — gives

4

spynner — spider

5

fyue wyttes of melancholy — (liberates)

203

2

Couelence — Coblenz

the five senses from the effects of

3

scole — school

"black bile," which is a depressant,

4

Empyricus — empiric, quack

(according to belief then current)

207

1

oxce — ox

6

unclennes — toxic matter

212

1

leues — leaves

10

yll humours — body fluids in a morbid

HIERONYMUS BRUNSCHWIG S BOOK OF DISTILLATION

157

Chapter Line

state; (according to medical beliefs
of the times, the cardinal humours were
the blood, cholcr [yellow bile],
melancholy [black bile], and
phlegm).
1 1 vaynes — veins

(second citation)

5 alopiciam — baldness

6 tryacle — treacle or theriac, a mixture of

many medicinal substances, formerly
believed to prevent or cure the
effects of poisons or poisonous bites.

Acknowledgment

The authors express their very deep thanks to Mr.
Lessing J. Rosenwald of the Alverthorpe Gallery,

Jenkintown, Pennsylvania, for his kind permission to
study his copy of the rare edition of Brunschwig's
Book of Distillation.

REFERENCES

1. Sicerist, Henry E. : Hieronymus Brunschwig and

His Work. New York, 1946.

2. Sudhoff, Karl: Deutsche Medizinische Inkunabeln.

Studien zur Geschichte dcr Mcdizin.
Heft 2/3. Leipzig, 1908, pp. 61-69.

3. Stillman, John M. : Chemistry in Medicine in

the Fifteenth Century. Scientific Monthly
6, 1918, pp. 167-175.

4. Sicerist, Henry E. : Medieval Medicine. Phila-

delphia, 1941.

5. Castiglioni, Arturo: A History of Medicine.

New York, 1941.

A Dozen Portraits in the College Hall 1

By FRED B.

ONE afternoon last year, Mr. Theo-
dor Siegl, Conservator of The
Philadelphia Museum of Art, on
invitation of the Committee on Mutter
Museum and College Collections, made a
walking tour of the College's portrait col-
lection. At that time, Drs. Wood, Gibbon
and Dyer, Mrs. Wade and Miss Garner,
Drs. Gefter, Holling and I were led on a
memorable excursion into the fields of art
and history. Mr. Siegl's expert review and
suggestions about the care and repair of
various paintings and drawings were
heeded and since then Mr. Will Brown,
also a member of the Art Museum staff,
has worked at the task of refurbishing the
College's fine arts holdings — supported by
a special fund voted by Council. The re-
sults of this effort have far exceeded the
cost and we have become increasingly
aware of the beauty and value of this re-
markable trove of Americana. I have
chosen a dozen of the College's portraits to
describe briefly at this gathering — por-
traits outstanding in terms of both artistic
merit and subject interest. These portraits
are located in the Hutchinson Room — off
the first-floor rotunda, in adjacent Thom-
son Hall, and in the second-floor foyer.
May this sample inspire us and stimulate
our interest in them and other art works
here which time does not permit me to
discuss.

Hanging above the paneled fireplace in
the Hutchinson Room is a three-quarter
length oil portrait of Dr. Nathaniel Chap-
man (1780-1853), painted by the English-
born portrait painter Thomas Sully in

1 Read at "an evening at the College," arranged
by the Entertainment Committee, 2 May 1969.

2 Chairman, Committee on Miitter Museum and
College Collections, The College of Physicians of
Philadelphia.

OGERS, m.d.~

1817 and presented to the College by Mrs.
Henry Cadwalader Chapman in 1909.

Thomas Sully (1783-1872), first a pupil
of Gilbert Stuart and later (in London) of
Benjamin West, established himself in
Philadelphia (1810), where he enjoyed con-
siderable popularity. His dashing brush-
work, seen in the Chapman portrait,
brings charm to its subject. Sully's other
sitters included four Presidents: Jeflerson,
Madison, Monroe, and Jackson. In her
youth, Queen Victoria sat for him.

Dr. Nathaniel Chapman, a native of
Virginia and descendant of Sir Walter
Raleigh, was a prominent teacher of
clinical medicine at his alma mater, the
University of Pennsylvania, for forty-six
years. A polished and witty aristocrat who
traveled in the highest circles of his day,
Chapman displayed literary and political
interests early in life by writing for The
Port Folio, a magazine founded in Phila-
delphia in 1801, and by editing four vol-
umes of Select Speeches, Forensick and
Parliamentary, in 1807-08. His marriage
to Rebecca Cornell Biddle of Philadelphia,
in 1808, was a fortunate one and their
family life was cordial. It is said that the
young doctor decided to marry his wife-
to-be on hearing about her — before their
actual meeting!

Chapman received his M.D. degree in
1801 and, after three years study abroad,
settled down to practice in Philadelphia.
In 1817 he established the Medical Insti-
tute of Philadelphia; it provided instruc-
tion for practitioners and has been con-
sidered the first 'postgraduate' medical
school in the United States. With the
publisher Matthew Carey, in 1820, Chap
man founded the Philadelphia Journal of
the Medical and Physical Sciences, which
seven years later adopted its present title,

A DOZEN PORTRAITS

1 VI

the American Journal of the Medical
Sciences. This periodical is still published
in Philadelphia, by Lea &: Febiger, and is
now the nation's oldest continuous medical
journal. Chapman was also a promoter of
the U. S. Pharmacopoeia, a drug com-
pendium first issued in 1820 and another
publication still active in the world.

Epidemic cholera struck Philadelphia
during the summer of 1832 — a dreadful
episode lasting several months. During
this period Dr. Chapman and his col-
leagues rendered valuable service in treat-
, ing the sick and setting up hospital
facilities for their care. Chapman was one
of thirteen physicians awarded silver
pitchers by the City of Philadelphia for
their heroic labors. The handsome pitcher
given to him is now on display here — a gift
in 1966 of his great-great grandson, Mr.
Sydney Thayer, Jr., of Bryn Mawr.

Prominent professionally and socially,
Nathaniel Chapman was chosen as the first
president of the American Medical Asso-
ciation at its organizational meeting in
Philadelphia on May 5, 1847. This cap-
stone of his career attested to the fact that
he stayed at the helm despite professional
controversies which raged around him in
a period of medical feuds and stormy as-
sociates. In the spring of 1850, illness
forced him to relinquish his teaching and
civic interests. He died on July 1, 1853, and
was buried at St. Stephen's Episcopal
Church — a church which he had helped
found in 1823.

A charcoal sketch of Sir William Osier
(1849-1919), done by John Singer Sargent
(1856-1925) at his London studio in 1914
and presented to this College in May of
that year by Lady Osier, shows the Cana-
dian-born physician in a pensive mood.
The artist Sargent, whose father was an
early ophthalmologist in Philadelphia, was
born in Italy and trained as a painter at
the Beaux-Arts in Paris. His first exhibit
(1877) attracted favorable notice, and by
1885, when he had settled in London, his

talents were in demand. Frank in depic-
tion, his portraits of beautiful women,
symbolic murals (Boston Public Library),
and landscapes in water color are much
admired.

William Osier aroused enthusiastic ac-
claim of colleagues and pupils during a
distinguished career in Canada, the United
States and England. A man of wide culture
and an expert physician, Osier was a
prolific writer and speaker on medical and
literary topics. In 1884, at age 35, he was
called to the chair of clinical medicine at
the University of Pennsylvania where he
actively pursued clinical and clinico-patho-
iogical studies. He afterwards referred to
his Philadelphia stay, especially his experi-
ences in the wards and deadhouse at
"Biockley," as the most instructive of his
career. (The deadhouse, now the Osier
Memorial Museum, still stands on the
Philadelphia General Hospital grounds.)
While in Philadelphia, Osier was also an
active member of the Library Committee
of The College of Physicians of Philadel-
phia, and he continued an interest in its
resources after leaving in 1889 to become
the first professor of medicine at the newly
founded Johns Hopkins Medical School at
Baltimore.

In Philadelphia too, Osier met and
married his wife, the widow Grace Revere
Gross; they were wed at St. James'
Episcopal Church in May 1892. Two years
later he returned to Philadelphia to speak
at the opening of The Wistar Institute of
Anatomy and Biology — and he willed his
brain to that institution to enrich its
neuroanatomical museum. Sir William
and Lady Osier died at Oxford, England;
their ashes and his 7,600 volume historical
library are now at his medical alma mater,
McGill University, Montreal, Canada.

The oil portrait of Dr. Charles Caldwell
(1772-1853), painted by Thomas Sully,
conveys the belligerent personality of the
subject. A native of North Carolina and
medical graduate of the University of

160

FRED B. ROGERS

Pennsylvania (1796), Caldwell occupied
the chair of natural history at the Univer-
sity from 1810-18. A pupil and friend of
Dr. Benjamin Rush, he subsequently
quarreled with him and the trustees. In
1818 Caldwell left Philadelphia for Lexing-
ton, Kentucky, where he became professor
of materia medica at Transylvania Univer-
sity, whose medical department he had
helped to organize. He moved to Louisville
in 1837 and established the Louisville
Medical Institute, afterwards merged into
the University of Louisville as its medical
school. Rivalry between the towns of
Louisville and Cincinnati brought Cald-
well a prominent role in the medical af-
fairs of the Mississippi Valley.

Caldwell's father had come to this
country from the North of Ireland. The
son, whose early opportunities for educa-
tion were limited, demonstrated extraor-
dinary ability — rising to head a literary
academy at age 18. While a medical stu-
dent he served valiantly in the yeliow fever
epidemic of 1793 in Philadelphia. Later
he was surgeon of a brigade during the
"Whiskey Insurrection" in the summer of
1794, an uprising of farmers in western
Pennsylvania against an excise tax on dis-
tilled liquors. His Autobiography, pub-
lished after his death (1855), is a remark-
able repository of medical scandal. Wil-
liam Osier, discussing "Some Aspects of
American Medical Bibliography" in 1902,
wrote of this book: "Caldwell's Auto-
biography is a storehouse of facts (and
fancies!) relating to the University of
Pennsylvania, to Rush and to the early
days of the Transylvania University and
the Cincinnati schools. Pickled, as it is, in
vinegar, the work is sure to survive."

An oil portrait of Dr. William Potts
Dewees (1768-1841), painted by John
Neagle (1796-1865), was given to the Col-
lege by its Fellow, Dr. I. Minis Hays
(1847-1925). The likeness of Dr. Dewees
shows a handsome, winning face.

Boston-born, John Neagle's professional

career was spent in Philadelphia. He
began work as an assistant to a coach
painter and by ability rose to be a re-
spected artist. His portrait of Gilbert
Stuart is the best one of that fascinating
personality. Neagle's famous full-length
canvas, "Pat Lyon at the Forge," graces the
Pennsylvania Academy of the Fine Arts, as
does a landscape, "View on the Schuylkill,"
the Art Institute of Chicago.

William Dewees was the great-grandson
of Swedish immigrants; his mother was a
daughter of Thomas Potts, founder of
Pottstown, Pa., where his grandson was
born. After medical training at the Univer-
sity of Pennsylvania, Dewees began prac-
tice at age 21 with an M.B. degree. After
practicing for some time, he returned to
the medical school and took his M.D.
degree in 1806. His doctoral thesis was en-
titled, "Lessening Pain in Parturition;"
Prof. William Shippen, Jr. called its mes-
sage an historic one.

In 1810 a professorship in obstetrics was
established at the University of Pennsyl-
vania with the proviso that student "at-
tendance should be optional for gradua-
tion." Dr. Thomas Chalkley James was
appointed to this chair. In 1825, Dewees
became adjunct professor, and nine years
later succeeded James. Dr. Dewees built up
a large obstetrical clientele and, "patients,
it was said, postponed their confinements
until he was at leisure" (Waterson). In
1824 he published his System of Midwifery,
which ran through twelve editions; in

1825, A Treatise on the Physical and
Medical Treatment of Children — the first
American textbook on pediatrics; and in

1826, On the Diseases of Females, both
books running to ten editions.

An oval portrait of Alexander von
Humboldt (1769-1859), German explorer,
naturalist and statesman, was painted by
Charles Willson Peale (1741-1827) on the
former's visit to Philadelphia in June 1804.
The artist, then aged 63, completed this
portrait in three days; his sitter was 35

A DOZEN PORTRAITS

K.l

years old. In this situation one genius
captured another on canvas. For Peale was
a man, like his friend, Benjamin Franklin,
of catholic interests and diverse talents.
Best remembered as a portrait painter, he
was also a civic leader, soldier and natu-
ralist. A pupil of John Singleton Copley in
Boston and Benjamin West in London,
Peale in 1805 was instrumental in founding
the Pennsylvania Academy of the Fine
Arts. Versatile in applied science and art,
he painted portraits of many leaders and
visitors in the early years of our nation.
(George Washington sat for Peale at least
seven times, and from these sittings the
artist produced sixty portraits of him.)
Thrice married, Peale was the father of
seventeen children, several of them very
talented.

Alexander von Humboldt, a disciple of
the great Goethe, traveled in South Amer-
ica, Mexico, and the United States during
the years 1797-1804. He explored the
course of the Orinoco and found the com-
munication between the waterways of the
Orinoco and Amazon Rivers. The Hum-
boldt Current — a cold Pacific Ocean cur-
rent flowing north along the coasts of Chile
and Peru, Humboldt River in Nevada,
Humboldt Bay ofl California, and Hum-
boldt Glacier — the world's largest — in
Greenland, honor his name. So does the
mineral Humboldtine (ferrous oxalate)
and Humboldt's Sea on the surface of the
moon. (Humboldt University in Berlin is
! named for the philologist, diplomat and
man of letters, Wilhelm von Humboldt
[17G7-1835], the elder brother of Alex-
ander.)

From 1808-27 Alexander resided in
Paris, collaborating with the French
scientist, Gay-Lussac, in chemical experi-
ments. Humboldt is credited with the first
description of choke-damp and fire-damp
in mines, and he devised a gas-mask and
safety lamp to protect miners from these
dangers. In 1829, under the patronage of
Czar Nicholas I of Russia, he led an ex-

pedition into North and Central Asia, by
which was extended our knowledge of
mountain chains, plant distribution and
climate. In 1830 Humboldt became envoy
from Prussia to France, serving in this
capacity for eighteen years. His last and
greatest work, Kosmos, a five-volume
treatise on natural philosophy published
between 1845-62, was widely translated.

A full-length oil portrait of Dr. William
Thomson (1833-1907), painted by Thomas
Eakins (1844-1916), adorns the rear wall of
the College hall named in his memory.
This large (74 x 48") portrait is our out-
standing item of recent years, the one most
borrowed for exhibit elsewhere and com-
manding the highest insurance premium.

Thomas Eakins, a life-long resident of
Philadelphia, studied art and anatomy
both at home and abroad before he began
teaching at the Pennsylvania Academy of
the Fine Arts (1876-86). Employing the
technical skill of an engineer, he laid out
perspective with mechanical drawings, and
his effort to capture body movement led
him to become a pioneer experimenter
with motion pictures. A realist, he painted
without romantic gloss, and late in life
began to enjoy a little of the superlative
reputation his name now holds. The Gross
Clinic (Jefferson Medical College) and The
Agneiu Clinic (University of Pennsylvania)
are favorite medical canvases by Eakins.

Dr. William Thomson, a graduate of
Jefferson Medical College in 1855, was an
early ophthalmologist in Philadelphia and
a pioneer in the study of refraction. With
Dr. William F. Norris, also a prominent
Fellow of this College, he promoted the
systematic refraction of patients' eyes.
With Dr. S. Weir Mitchell, Thomson drew
attention to the importance of "eye-strain"
as a cause of headache, which refraction
often relieved. He was also interested in
color-blindness and modified Holmgren's
wool-skein test for its detection. Himself
affected with hypermetropia, he made im-
portant investigations on this condition

162

FRED II. ROGERS

and also on astigmatism. Dr. Thomson
served with the Union Army Medical
Corps during the Civil War, was surgeon
to Wills Hospital from 1872-77, and par-
ticipated in the International Medical
Congresses of 1872, 1876 and 1881.

A portrait of Dr. Plunket Fleeson
Glentworlh (1769-1833), painted in oils by
Gilbert Stuart (1755-1828), depicts the sub-
ject wearing a ruff, jabot and lace shirt-
cuffs, and holding a book in his right
hand. This portrait, which was exhibited
in the Pan-American Exposition at Buffalo,
N. Y., in 1901, was donated to the College
in 1948 by the doctor's great-grandchildren,
Henry R. and Marguerite L. Glentworth.

Gilbert Stuart, born in Rhode Island,
was the most celebrated portrait painter of
his day. For five years (1775-80) he studied
in London under Benjamin West, whose
star pupil he became. After achieving
fame in London and Dublin, he returned
to America in 1792. In New York and
Philadelphia (1792-96), Stuart made three
portraits of Washington, painted from
life. Among Stuart's other sitters were
Presidents Jefferson, Madison, and Mon-
roe. In 1805 he settled in Boston, where his
reputation allowed him to select his com-
missions. At their best his character studies
are lifelike and luminous, and they have
given him an unrivaled reputation in
American portraiture.

Dr. Plunket Glentworth was the son of
Dr. George Glentworth (1735-92), one of
the founders of this College in 1787, and
his wife nee, Margaret Linton. The son,
who is mentioned in the famous novel,
"The Red City," by Dr. S. Weir Mitchell,
took his M.D. degree at the University of
Pennsylvania in 1790. In the following
year he served as secretary of the Univer-
sity, and in 1792 was elected a Fellow of
The College of Physicians of Philadelphia.
He counted George Washington among his
patients. In a letter dated April 20, 1797,
our first President wrote: "Thanks to the
kind attention of my esteemed friend Dr.

Glentworth . . . than whom no nobler man
nor skilful physician ever lived, I am now
restored to my usual state of health."

Dr. Glentworth, in 1805, was one of the
founders of the Pennsylvania Academy of
the Fine Arts at Philadelphia. Thereafter
he moved to Trenton, N. J., where he
served as a warden of St. Michael's
Episcopal Church from 1820-24. During
this interval he was physician to Joseph
Bonaparte, exiled brother of Napoleon I,
at the former's estate, "Point Breeze," in
nearby Bordentown. A busy and fashion-
able practitioner, Dr. Plunket Glentworth
died in January 1833, and was interred in
the family vault at Old St. Paul's Epis-
copal Churchyard, Philadelphia.

An oil portrait of Georges Cuvier (1 769—
1832), painted by Rembrandt Peale (1778-
1860), pictures an eminent French natu-
ralist and statesman. The red ribbon of the
Legion d'Honneur decorates his left coat
lapel.

A son of Charles Willson Peale, Rem-
brandt Peale was, like his father, a pupil
of Benjamin West, and on his return from
Europe, devoted himself chiefly to por-
traiture. An original member of the Na-
tional Academy of Design, in 1825 he suc-
ceeded John Trumbull as president of the
Academy of Fine Arts. Rembrandt Peale's
idealized likeness of George Washington
(1823) hangs in the National Capitol.

Georges Cuvier was born in Mont-
beliard, France. Inspired by the work of
Buffon, he studied natural history at the
Academy of Stuttgart, Germany. In 1795
he was appointed assistant to the professor
of comparative anatomy at the Museum
National d'Histoire Naturelle in Paris. An
investigator in zoology, geology and
paleontology, Cuvier greatly advanced the
science of comparative anatomy. His name
is recalled by the embryological ducts of
Cuvier: two short venous trunks in the
fetus opening into the atrium of the heart;
the right one becomes the superior vena
cava.

A DOZEN PORTRAITS

163

Cuvier's greatest work is Le Rcgne
Animal (The Animal Kingdom), 1817, a
treatise in which he arranged all organisms
in the four great classes of vertebrates,
mollusks, radiates and articulates. He be-
came perpetual secretary of the French
Academy of Science in 1803, and councilor
of the Imperial University five years later.
Napoleon I made him a councilor of state
in 1814, and Louis Philippe named him a
peer of France seventeen years later.

At Cuvier's suggestion, in 1819, the
world's first independent professorship of
pathological anatomy was established at
the University of Strasbourg. Dr. Jean F.
Lobstein (1777-1835), author of a Traite
d'anatomie pathologique (1829), occupied
this chair. Lobstein's disease, osteogenesis
imperfecta, recalls his name.

Cuvier made significant contributions to
science, but he was a foe of the evolution-
ary ideas of Lamarck and Darwin. Louis
Agassiz (1807-73), Swiss-born physician-
naturalist of Harvard University, was a
favorite pupil of Baron Cuvier at the Paris
Jardin des Plantes before coming to the
United States.

The bust portrait of Joseph Louis Gay-
Lussac (1778-1850), by Rembrandt Pcale,
is a companion in size and style to that of
Georges Cuvier by the same artist. Each
was presumably painted from life before
Peale returned to Philadelphia from Eu-
rope in the year 1810. The artist's signa-
ture appears in the lower right corner of
the canvas front on the Gay-Lussac por-
trait: "painted in wax by Rem. Peale
1810.''

Gay-Lussac, an eminent French scientist,
pioneered in the study of the gaseous
state. In 1804 he made the first balloon
ascension for the purpose of scientific in-
quiry, rising on a second ascent in that
;year to over 23,000 ft. above sea level. This
work placed him among the founders of
meteorology. In 1808 he traveled to Italy
with Alexander von Humboldt to study
the law of magnetic declination. In the

same year he was appointed professor of
physics at the Sorbonne — a position be-
held for twenty-four years. In 1810 he also
became professor of chemistry at the
Ecole Polytcchnique in Paris. During the
years 1823-24, the brilliant German chem-
ist, Justus von Liebig, worked with him in
his laboratory.

With Humboldt, Gay-Lussac carried on
ail investigation of the polarization of
light. In chemistry he discovered ethyl
iodide, hydrosulfuric and hypochlorous
acids. Gay-Lussac's gas law recalls his
name: at a constant pressure the volume of
a given mass of perfect gas varies directly
with the absolute temperature.

An oil portrait of Dr. Thomas Cooper
(1759-1839), painted by Charles Willson
Peale, captured the scowl of an agitator
and freethinker of his day. A student at
University College, Oxford, trained in law
at the Temple, Cooper attended anatomi-
cal lectures in London, took a clinical
course at Middlesex Hospital and later at
Manchester attended patients under a
preceptor. But for his father's insistence
upon the law, he probably would have be-
come a practicing physician. In 1817 a
University of New York conferred upon
him the honorary degree of M.D., which
he flaunted thereafter.

In 1794 Cooper emigrated from England
when he was threatened with persecution
because of his strong sympathies for the
French Revolution. A prolific author, he
had already published writings on educa-
tion, history, law, electricity and optics. In
the United States, he practiced law at
Northumberland, Pa. until 1804, then
served as a state judge for Luzerne County
until 1811. While editor of a violently-
Republican newspaper, Cooper's slander-
ous attacks on President John Adams in
the matter of the Alien and Sedition Acts
led to his being fined and imprisoned.
Adams dubbed Cooper a "learned, in-
genious, scientific, and talented madcap."
Judge Cooper was subsequently impeached

164

FRED B. ROGERS

and removed from the Pennsylvania bench
because of the freedom ami force of his
opinions.

Like his friend and fellow-exile, the Rev.
Joseph Priestley, with whom he collabo-
rated in scientific research, Cooper was
esteemed by President Thomas Jefferson.
The latter procured Cooper's appointment
in 1811 as first professor of natural science
and law at the University of Virginia. At
that time Jefferson called him "the great-
est man in America in the powers of his
mind and acquired information and that
without single exception." Cooper, how-
ever, resigned the appointment due to the
delay in opening the university and be-
cause his Unitarian religious views were so
hotly denounced by the Virginia clergy.

After teaching chemistry at Dickinson
College (1811-15) and the University of
Pennsylvania (1815-19), Cooper accepted a
chair in chemistry at the University of
South Carolina. Elected president of the
institution in the following year (1820), he
also taught political science. His Lectures
on the Elements of Political Economy,
published in 1826, was a pioneer textbook
on the subject.

Though heralded for his enlightened
views on education, Cooper's vehement
anticlericalism led to a 'trial' for atheism,
and to his resignation from the South
Carolina university presidency in 1834. A
champion of free trade and state sover-
eignty and an advocate of the institution
of slavery and political nullification, he
helped prepare the way for secession. At a
spirited anti-tariff meeting at Columbia,
S. C, in 1827, Cooper asked his listeners,
"Is it worth our while to continue this
Union of States, where the North demands
to be our masters and we are required to
be their tributaries?"

President John Quincy Adams shared
his father's dislike for "Old Coot" — to
borrow a student nickname applied to
Cooper by the gynecologist, Dr. J. Marion
Sims. Adams wrote in 1838 of the "English

atheist South Carolina Professor, Thomas
Cooper, a man whose very breath is
pestilential to every good purpose." It is
recorded that at Cooper's funeral, his firm
supporters and ardent detractors found it
difficult not to resort to blows!

In contrast to the stormy petrel just de-
scribed, the oil portrait of Dr. Robley
Dunglison (1798-1869), painted by
Thomas Sully in 1868, reflects the kindly
manner of the man. With full beard, it
shows the well-liked physician late in life.
Dr. Dunglison and his wife, Harriett, were
devotees of music: this portrait formerly
belonged to the Musical Fund Society, of
which Dunglison was a president, and
from which it was purchased for the Col-
lege in 1957 by Drs. Jonathan E. Rhoads
and Lewis C. Scheffey.

A native of Keswick, England, trained in
London, Edinburgh and Paris, Robley
Dunglison took his M.D. degree at the
University of Erlangen in Germany (1823).
Two years later he was imported by
Thomas Jefferson to establish the school of
medicine at the University of Virginia.
Moving thence to the University of Mary-
land (1833-36), he finally settled at the
Jefferson Medical College of Philadelphia
(1836-68), where he was professor of physi-
ology and later dean of the faculty. Dun-
glison was a respected leader during an era
of stormy Hippocrats. Dr. Oliver Wendell
Holmes once described him as "the great
peace-maker." A skilled practitioner, he
attended at times Presidents Jefferson,
Madison, Monroe, and Jackson.

Dr. Dunglison compiled an excellent
medical dictionary which went through 23
editions, and wrote a wide array of text-
books on nearly every subject but surgery.
Much interested in pediatrics and preven-
tive medicine, he recognized a type of
chronic hereditary chorea in adults, now
called Huntington's chorea, thirty years
before Dr. George Huntington fully de-
scribed the disorder in 1872. Dunglison's
course of lectures on medical history was

A DO/.F.N PORTRAITS

165

published posthumously by a physician-
son as the "History of Medicine from the
Early Ages to the Commencement of the
Nineteenth Century."

An oil portrait of Dr. William Williams
Keen (1837-1932), president of this Col-
lege in 1900-01, painted by James L. Wood,
shows the great surgeon in a sitting pose
with his Phi Beta Kappa key from Brown
University (1859) conspicuously displayed.
Mr. Wood, the artist, was an exhibitor at
the Pennsylvania Academy of the Fine Arts
from 1893-99. He painted four other por-
traits owned by the College, those of Drs.
Joseph Leidy, Frederick A. Packard, Na-
thaniel A. Randolph, and Horatio C.
Wood.

W. W. Keen is best remembered as a
pioneer in neurosurgery; he successfully
removed a meningioma in 1888, tapped
the cerebral ventricles in the following
year, and gradually acquired wide experi-
ence in the extirpation of brain tumors. He
was an eloquent American supporter of
Dr. Joseph Lister's doctrine of antisepsis,
and was among those who welcomed the
great British surgeon on his visit to Phila-
delphia in 1876.

In his final year of medical school, Keen
left Jefferson Medical College to serve
with the Union Army. Returning to ob-
, tain his M.D. degree in 1862, he saw two
more years of service as a medical officer —
I including the Battle of Gettysburg. Also
■ during the Civil War he worked with Drs.
S. Weir Mitchell and George B. Morehouse
at the Turner's Lane Military Hospital in
Philadelphia, a 275-bed center for neuro-
logical casualties. These three men made
important studies of gunshot and other
wounds which were afterward expanded
into an important book, Injuries of Nerves
and their Consequences (1872).
Dr. Keen became professor of surgery at
; the Woman's Medical College of Penn-
, sylvania in 1884, and assumed the chair of
, surgery at Jefferson five years later. In

September 1893, when a financial panic
was threatening the nation, President
Grover Cleveland's physician urged exci-
sion of a large malignant-looking ulcer
from his patient's hard palate. After care-
ful planning, Cleveland was operated upon
aboard a yacht, the Oneida, off New York
City. Two surgeons — Drs. Joseph D. Bry-
ant of New York and W. W. Keen of
Philadelphia, an anesthetist, a dentist and
an internist were the professional team.
Cleveland's right upper maxilla was re-
sected and a prosthesis fitted. The opera-
tion having been kept a secret, the
President was able to appear before a joint
meeting of Congress a month later — to
bolster confidence and avert financial
turmoil. Dr. Keen subsequently wrote an
account of the surgery, and Cleveland's
right upper jaw with several teeth and the
cheek retractor Keen used on that historic
occasion are now in the Mutter Museum.

Dr. Keen served with the Army Medical
Corps in three wars: Civil War, Spanish-
American War, and World War I. From
1876-89 he taught anatomy to students at
the Pennsylvania Academy of the Fine
Arts. Of Baptist persuasion, he was
deeply religious and wrote a book entitled
/ Believe in God and Evolution (1922). He
died at the age of 95, full of years and
honor.

With the portrait of Dr. Keen, painted
in 1901, we come into this century and
conclude our brief tour. Like Cesare, the
somnambulist in the cinema classic The
Cabinet of Dr. Caligari, the casual visitor
to The College of Physicians of Philadel-
phia may be unaware of the wonders
around him. Although I cannot compare
myself to the late Werner Krauss in the
role of guide, it is a pleasure to introduce
you to a few of the treasures of art, litera-
ture, science and healing in the handsome
Hall of the College. Each person is free to
choose a favorite from among the varied
attractions that we share.

List of the Kate Hurd Mead Lectures in
Medical History, I-XX

THE Kate Hurd Mead Class of 1888
Lectures in Medical History, of the
Woman's Medical College of Pennsyl-
vania, are regularly presented at The Col-
lege of Physicians of Philadelphia under
the joint auspices of its Section on Medical
History and the Woman's Medical College
of Pennsylvania. A number of the lectures
were not published in the College's Trans-
actions & Studies because of the imminent
appearance of the materials in books sched-
uled for publication by the lecturers.

I. Pepper, O. H. Perry: Medical History in
Medical Words (13 Jan. 1950), Trans. &
Stud. Coll. Phys. Philadelphia, 4th s., 18:
29-37, April, 1950.
II. Bett, Walter R. : The Pathology of
Genius (13 Feb. 1950).

III. Shryock, Richard H.: Women in Ameri-

can Medicine (14 April 1950).

IV. Leake, Chauncey D. : The Old Egyptian

Medical Papyri (17 April 1952).
V. Nettleship, Anderson: A View of What
Primitive Man Thought of Disease (26
Feb. 1953).

VI. Tucker, David A., Jr.: Medical Education
and Practice in the Ohio Valley, 1780-
1860 (25 March 1954).
VII. Stevenson, Lloyd G. : Biography versus
History, with Special Reference to the
History of Medicine (21 April 1955),
Trans. & Stud. Coll. Phys. Phila., 4th s.,
23: 83-93, Aug., 1955.
VIII. Finch, Jeremiah S. : The Lasting Influence
of Sir Thomas Browne (3 April 1956),
Trans. & Stud. Coll. Phys. Phila., 4th s.,
24: 59-69, Aug., 1956.
IX. Stevenson, R. Scott: The Changing Scene
in Harley Street (9 April 1957), Trans.
& Stud. Coll. Phys. Phila., 4th s., 25:
87-96, Aug., 1957.

X. Tilton, Eleanor M. : Science and Senti-
ment: a Study of Oliver Wendell Holmes
(15 April 1958), Trans. & Stud. Coll.
Phys. Phila., 4th s., 26: 89-98, Aug., 1958.
XI. West, Herbert F. : Rabelais, Sterne, and
Osier (7 April 1957), Trans. & Stud. Coll.
Phys. Phila., 4th s., 27 : 60-73, Oct., 1959.
XII. Miller, Genevieve : The Unicorn in Medi-
cal History (19 April I960), Trans. &
Stud. Coll. Phys. Phila., 4th s., 28: 80-93,
Oct., 1960.

XIII. Wright, Arthur Dickson: The History of

Opium (21 Feb. 1961), Trans. & Stud.
Coll. Phys. Phila., 4th s., 29: 22-27,
July, 1961.

XIV. Schmidt, Carl F. : Some Experiences with

Chinese Drugs (27 March 1962), Trans. &
Stud. Coll. Phys. Phila., 4th s., 30: 66-72,
Oct., 1962.

XV. Corner, George W. : George Hoyt Whip-
ple, Nobel Prize Pathologist (19 March
1963), Trans. & Stud. Coll. Phys. Phila.,
4th s., 31: 40-41, July, 1963.
XVI. Rose, Edward: John Coakley Lettsom and
English Medicine in the Georgian Period
(21 April 1964), Trans. & Stud. Coll.
Phys. Phila., 4th s., 32: 57-59, Oct., 1964.
XVII. Bell, Whitfield J., Jr.: James Hutchin-
son . . . Letters from an American Student
in London (26 April 1966), Trans. &
Stud. Coll. Phys. Phila., 4th s., 34 : 20-25,
July, 1966.

XVIII. Polcino, Sister M. Regis: The Medical
Mission Sisters (18 April 1967), Trans. &
Stud. Coll. Phys. Phila., 4th s., 35: 1-25,
July, 1967.

XIX. Lesky, Erna : History of the Vienna General
Hospital (13 Feb. 1968).
XX. Rogers, Fred B. : Dr. William Bryant
1730-86: American Physician and Anti-
quary (15 April 1969), Trans. & Stud.
Coll. Phys. Phila., 4th s., 37: 99-105, Oct.,
1969.

W. B. McDaniel, 2d

166

Memoir of William Bates
1889-1967*

By NORBERT

DR. William Bates was born in
Philadelphia on April 11, 1889.
He received his B.S. degree from
the University of Pennsylvania in 1912 and
was awarded his medical degree from the
same institution in 1915. Dr. Bates in-
terned at the Hospital of the University of
Pennsylvania. He served his country in
World War I in Base Hospital Unit No. 20
from 1917 to 1919. From the rank of Major
he rose to the rank of Lieutenant Colonel.
The University of Pennsylvania appointed
him Professor of Surgery in 1935 and
Chairman of the Graduate School of Sur-
gery in 1946.

Dr. Bates was happiest when he was
teaching and helping his residents and
students at the University of Pennsylvania
Graduate School and on the staffs of the
hospitals with which he was associated.
These included the Graduate Hospital,
Presbyterian Hospital, Medical Chirurgi-
cal, Howard, Babies, American Stomach,
and Wills Eye. He had a great talent for
organizing. He spent many hours daily to
improve the courses and the curriculum for
the Graduate School. He wrote many
papers covering a broad scientific spectrum
but he had a special interest in the relief
of pain and its differential diagnosis. He
was given the Strittmatter Award by the
Philadelphia County Medical Society for
the year 1953. Later he continued his
teaching as Director of Education and
Research at the Harrisburg Polyclinic
Hospital in 1957 until his death.

• Read before The College of Physicians of Phila-
delphia, 9 October 1968. Prepared and published at
the request of the Council of The College of Phy-
sicians of Philadelphia.

. SCHULZ, M.n.

Dr. Bates was a very active member of
many societies. He served as President for
each of the following organizations: Aescu-
lapian Club, Medical Club of Philadel-
phia, Physicians Motor Club, Philadelphia
County Medical Society and the Penn-
sylvania State Medical Society. He served
as a trustee for the U.S. Chapter of the
World Medical Organization. Dr. Bates
was active in the American Medical Associa-
tion in the House of Delegates. He was a
member of The College of Physicians of
Philadelphia and of the Academy of Surgery
of this city.

Dr. Bates was a member of the Union
League of Philadelphia. He was a trustee
of the First Presbyterian Church of Phila-
dephia. He was a 32nd Degree Mason.

His pace was formidable. Despite the
demands of a surgical practice as Chief of
Surgery in no less than two hospitals
simultaneously, he still found time to aid
a young aspiring surgeon or student. He
radiated kindness and humor. Hosts of
Philadelphians loved him as a friend. He
was widely sought to act as toastmaster
with his ready fund of stories. Who, having
heard, can forget his version of the Biblical
David and Goliath?

Dr. Bates and Marie Bergstresser of Har-
risburg were married in 1919. They shared
a devoted relationship until her death in
1955. They are survived by a son William
Bates, Jr., a vice president of the Phila-
delphia National Bank, and a daughter,
Mrs. Robert W. Moore, residing in Easton,
Pennsylvania. Five grandchildren are
living and remembering him.

William Bates died quietly at a friend's
home in Harrisburg, on February 22, 1967.

168

NORBERT J. SCHULZ

His family, friends, medical colleagues and
patients have been spiritually and mate-
rially enriched by his life. The memory of
this man remains warm and glowing de-

spite the passing of time. This happy
after-image is a living tribute to one who
sincerely dedicated his life to serving his
fellow man.

Memoir of Martin W. Clement
1 88 1- 1 966*

By JOHN KAPP CLARK, m.d.

MARTIN W. CLEMENT, Honorary
Associate of The College of Phy-
sicians, a descendant of prominent
Colonial ancestors, was born in Sunbury,
Pennsylvania, on December 5, 1881. In 1901,
he obtained his B.S. degree from Trinity
College in Hartford, where he had been a
member of St. Anthony Hall and a member
of the varsity football and basketball squads.
He went to work almost immediately with
the Pennsylvania Railroad, where he was
rapidly promoted to positions of increasing
responsibility from his initial job as an
eleven-dollar-a-week rodman. He was ap-
pointed Vice President in charge of opera-
tions in 1926, elected to the Board of Di-
rectors in 1929, and became President in
1935. At this time his predecessor, the late
General William W. Atterbury, described
him as the ablest railroad executive in the
country. Under Mr. Clement's leadership,
the railroad completed the electrification of
its eastern lines, started by his predecessor
during the depression years, the largest im-
provement program in the road's history.
Also constructed during his presidency was
the main Pennsylvania Station at 30th and
Market Streets in Philadelphia. It was under
his leadership that the railroad met the tre-
mendous transportation challenge of World
War II, running 29,670 extra trains with
400,00 cars to transport almost one and a
half trillion tons of freight and 18 million
servicemen, exclusive of furloughs. He be-
came a trusted consultant of General
George C. Marshall and many other high
government officials.
During his career, he maintained an ac-

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

tive interest in his alma mater and is cred-
ited as being creator of the modern Trinity
College. Mr. Clement was extremely inter-
ested in young men and was responsible for
recruitment of many Trinity students who
were both athletes and good scholars. He
felt strongly that the education they were
to receive should train them to fulfill their
responsibilities as citizens of the community.
On one occasion he said, "Some men are
only intelligent and are of no use at all.
Unless a teacher, a doctor, a scientist, a law-
yer, a minister or a businessman has in addi-
tion to intelligence good judgment, common
sense, integrity and good physical stamina,
he cannot excel in his profession or as a
citizen." On numerous occasions he ex-
pressed his strong feeling that the qualifica-
tions of an individual most likely to result
in success were a willingness to accept indi-
vidual responsibility and a sense of self-
discipline. His own life represented one of
the best examples of the results of such per-
sonal characteristics.

Mr. Clement was greatly interested in
medical affairs being, among other things,
one of the Board of Managers of the Hos-
pital of the University of Pennsylvania. The
College of Physicians of Philadelphia also
became one of his major interests. He re-
spected its rich traditions and service to
medicine and determined to do what he
could to insure its continued viability and
vigor. His influence with several charitable
foundations led to the donation of about
half the funds needed for the construction
in the early 1950's of the new wing to the
College building.

He was director of numerous corporations
and a member of many clubs and organiza-
tions including the Society of the War of

169

170

JOHN KAPP CLARK

1812, the Baronial Order of the Magna
Carta, the Colonial Society of Pennsylvania,
the Society of Colonial Wars and the Sons of
the Revolution. He was also a member of
the Philadelphia Club, the Union League,
the Merion Cricket Club, the St. Anthony
Club, the Rabbit and the Gulph Mills Golf
Club. In personal life his hobby was garden-
ing.

At 3 o'clock on the afternoon of Sep-
tember 1, 1966, every train of the Pennsyl-
vania Railroad came to a halt for one min-
ute while 59,000 employees stood silent.
The moment marked the beginning of the

hour of his funeral service in the Church of
the Redeemer in Bryn Mawr, where he had
been a member for many years and at one
time served on the vestry. Martin Clement
is survived by two sons, Harrison H., a
Philadelphia attorney, and James H., of
Kingsville, Texas; a daughter, Miss Alice
W. Clement, of West Berlin, Germany; a
brother, Colonel John K. Clement, of Har-
risburg; nine grandchildren and five great-
grandchildren. He will be remembered by
his many friends and associates as a man
who profoundly influenced their lives for
the better.

Memoir of Edward Foulke Corson
1883-1967*

By HERMAN BEERMAN, m.d.

ON December 2, 1967, The College of
Physicians of Philadelphia lost one
of its distinguished Fellows, Edward
Foulke Corson. Dr. Corson was elected to
Fellowship in 1914. His life was dedicated
to medicine, especially dermatology, and to
his family.

Dr. Corson was born at Jefferson Bar-
racks, Missouri, on November 29, 1883. He
was the son of Mary Ada Carter Corson, one
of the Carters of Virginia, and Major Joseph
K. Corson, M.C., an Army medical officer
and recipient of the Congressional Medal of
Honor.

After spending his early years in various
Army posts throughout the West and in
Washington, D.C., he came to Plymouth
Meeting, Pa., on his father's retirement. He
immediately entered Germantown Acad-
emy. After completion of his studies in this
venerable institution, Edward Corson en-
tered the University of Pennsylvania. He
was awarded the degree of Doctor of Medi-
cine in 1906. He spent two years as an intern
at the Episcopal Hospital. Following this,
he entered practice in Cynwyd, Pa.

Because of his intense interest in derma-
tology, Dr. Corson became closely associated
with the late Dr. Frank Crozier Knowles,
also a University of Pennsylvania graduate,
who was connected with various clinics in
I Philadelphia and subsequently became Pro-
fessor of Dermatology at Jefferson Medical
College (1920-1948). At Jefferson, Dr. Cor-
son's status rose from Associate in Derma-
tology (1921-1925) to Clinical Professor in
1939. This latter position he held until 1947
when he was made Professor Emeritus. In

• Prepared and published at the request of die
Council of The College of Physicians of Phila-
delphia.

1949 he served as interim head of the de-
partment.

Dr. Corson also gave generously of his
time to a number of Philadelphia hospitals:
Children's Hospital, 1910-1930; Presby-
terian Hospital, 1911-1921, and the Chest-
nut Hill Hospital, 1921-1939.

In addition to his ability as a practitioner
and teacher, Edward Corson was interested
in investigation and was the author of a
number of papers on various aspects of
dermatology, including poison ivy derma-
titis, the length of hair, and especially the
"cutaneous changes associated with rimless
spectacles." This last mentioned study,
made with Dr. Herbert A. Luscombe, the
present head of the Department of Derma-
tology at Jefferson, was instrumental in
helping to popularize the use of spectacles
with rims.

Dr. Corson was in the "Founders" group,
who were the first individuals to be certified
by the American Board of Dermatology and
Syphilology, as it was then known. He was
active in many medical organizations in
addition to The College of Physicians.
Among them are the American Dermatolog-
ical Association, the American Academy of
Dermatology, and the Philadelphia Der-
matological Society. He was a member of
the Sigma Xi, honorary scientific group
organization. He was President of the Phila-
delphia Dermatological Society in 1924 and
1951. During his second term, he had the
distinction of presiding on the occasion of
the Fiftieth Anniversary Meeting of the
Philadelphia Dermatological Society. In
1911 and in 1934 Dr. Corson was Chairman
of the Section on Dermatology and Syphil-
ology of the Medical Society of the State
of Pennsylvania.

171

172

HERMAN BEERMAN

As a result of his heritage and boyhood
spent in pioneer historic sites, Dr. Corson
developed a profound interest in history,
especially military history. This led to his
hobbies, among which was the collection of
British War medals, which Dr. Corson gave
to the Mutter Museum and which in 1966
were presented to the Museum of Medical
History of Johannesburg, South Africa.

He belonged to the Military Order of the
Loyal Legion, as did his father before him.
He also held membership in the Society of
Indian Wars, the Welcome Society and the
Union League of Philadelphia. Early in his
career, Dr. Corson joined the Army Medical
Corps and served in France during World
War I and later in the Army of Occupation

in Germany. He ultimately attained the
rank of Lieutenant Colonel.

Dr. Corson was a devoted husband and
father. In 1917 he married the former
Esther Bisler. This union resulted in a
daughter, Mrs. Edward W. Wetmore, a son,
Dr. Joseph K. Corson, and seven grand-
children. Dr. Corson was extremely proud
that his son became a dermatologist and As-
sociate Professor of Dermatology at Jeffer-
son Medical College.

Always a quiet, soft-spoken man, Dr. Cor-
son had many admirers. His opinion, based
on keen observation, was highly respected
by his colleagues. His passing is a great loss
to the medical world.

Memoir of John Arthur Daugherty
1902-1968*

By ALLEN W. CROWLEY, SR.

TOHN Arthur Daugherty, m.d., was
I born August 12, 1902, at Carlisle,
Pennsylvania. His early education
was in Harrisburg. He was graduated from
the University of Pennsylvania in 1924 and
from Jefferson Medical College in 1928.
After internship and residency training at
the Harrisburg Hospital, he remained
there as an attending physician until his
sudden death at his home on August 28,
1968.

Besides being Chief of Staff of the Har-
risburg Hospital just prior to his death,
he was also a member of many state and
national professional organizations, includ-
ing the American Diabetic Association,
American Heart Association, and the
American College of Physicians. He was a
delegate to the Pennsylvania Medical So-
ciety. He became a member of The College
of Physicians of Philadelphia in 1955.

He became a corporate member of the
Medical Service Association of Pennsyl-

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

vania (Blue Shield) in 1944, elected Presi-
dent in 1945, and became Chairman of
the Board in 1966. During this time he
served one term as President of the Na-
tional Association of Blue Shield Plans.
At the time of his death he was a Director
and Chairman of the By-Laws Committee.

His greatest service to organized medi-
cine has been in the area of prepay medi-
cal care. He was largely responsible for the
steady growth of the Blue Shield Plans,
both state and national. It was through
his efforts that Blue Shield grew from a
"paper" organization to the largest Blue
Shield plan in the United States, serving
all of Pennsylvania.

He was a tireless worker and a good
physician. He will be missed by his many
patients and friends as well as by his as-
sociates at Blue Shield.

Dr. Daugherty is survived by his wife
and three sons, Richard M., Ronald M.
and the Reverend Robert M., and also by
a sister, Mrs. Clarence E. Ulrich, and a
brother, J. Dwight Daugherty, fk.d., of
Kutztown, Pennsylvania.

173

Memoir of John Evan Davis, Jr.
1908-1968*

By BALDWIN L. KEYES, m.d.

BORN in Ashland, Pennsylvania, on
April 18, 1908, John Evan Davis, Jr.,
completed high school there and
went on to Pennsylvania State College for
his Bachelor of Science degree in 1930. He
entered Jefferson Medical College and ob-
tained his Medical Doctorate in 1933.

After an internship in the Cooper Hos-
pital of Camden, he was appointed to the
staff of the New Jersey State Hospital in
Trenton, and quickly became Chief of
Men's Service.

In 1941, Dr. Davis was called to active
duty in the Army as a Reserve Officer and
eventually became Chief of Neuropsychiatry
at Stark General Hospital, in Charleston,
South Carolina, where he served as Colonel
until 1946.

After the War he took graduate work at
Columbia University in New York, Rutgers
University in New Jersey, and The Research
Institute in Illinois. He then returned to
Trenton State Hospital as Clinical Director.

In 1948, he was called to Washington,
D. C, to the headquarters of the Veterans
Administration to organize and direct their
Psychiatric Out-patient Services throughout
the country.

When the Eastern Pennsylvania Psychi-
atric Institute became a fact in 1950, Dr.
Davis was promptly selected to become the
Medical Director of this important institu-
tion in Philadelphia to carry on treatment,
research and training programs.

During his eight years as Director of this
Institution, his accomplishments were so
recognized throughout the country that he
received many offers for state and national

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

opportunities, but he remained here
through his interest in the work being done
in Pennsylvania.

Meanwhile, among his many activities,
Dr. Davis functioned as Chief of the Psychi-
atric Consultation Service at Philadelphia
General Hospital and as President of the
Philadelphia Psychiatric Society.

He served as Chairman of The Technical
Review and Program Design while on the
Executive Committee of the Governor's
Comprehensive Mental Health/ Mental Re-
tardation Plan. He was a delegate to the
White House Conference on Aging.

In 1958, Governor Leader of Pennsyl-
vania appointed Dr. John E. Davis, Jr.,
Commissioner of Mental Health and
Deputy Secretary of Public Welfare. Dr.
Davis carried this position with such out-
standing ability that Governor Lawrence,
and subsequently Governor Scranton, reap-
pointed him to the same post to continue
the program he was accomplishing.

In 1963, Dr. Davis withdrew from public
service and accepted a Professorship in Psy-
chiatry at Jefferson Medical College and was
appointed Associate Head of the Depart-
ment.

At Jefferson, in addition to other duties,
Dr. Davis took over the responsibility for
the Residents Training Program, where his
experience with people, and with many hos-
pitals and with thousands of patients, came
to an intensely useful focus.

To list the professional attainments and
the services rendered by Dr. Davis to his
state and country would fill many pages,
for he was extremely active, giving talks
when called upon all over the country and
always helping to solve problems and to

174

BALDWIN L. KEYES

175

modernize psychiatric services in many
areas.

It is appropriate that the John E. Davis
Community Mental Health Center at Jeffer-
son has been named in his honor.

While summarizing the career of John
Davis, we have not touched upon the most
important factor of all, the man himself.

As a boy in Ashland, John Davis met a
girl who stayed close to his heart all of his
life. He married Margaret Yost while he was
an intern and she a student at Temple Uni-
versity. Thereafter, wherever he went, she
went also. Margaret Davis shared John's
problems and successes and contributed im-
measurably to his accomplishments.

Their lovely daughter, Gwenn, with de-
grees from Wellesley, Oxford and Michigan,
and now a professor at Bryn Mawr College,
has always been a joy, a sustaining factor

and stimulus throughout the happy, suc-
cessful life that these people have enjoyed
together.

John was a loveable, cheerful fellow; loyal
to his Welsh ancestry; proud of his family;
enthusiastic about his work — whatever it
happened to be; kindly and considerate; and
never too hurried to listen to those in
trouble and to help them solve their prob-
lems.

Always a gentleman, a physician and a
true humanitarian. When he slept away
from us on May 2nd, 1968, we lost one of
our most valuable people.

Now and then, as we walk through life,
we are joined by a warm friend who strolls
along with us and makes our way happier
by his presence and richer for the knowing
of him. . . .

. . . Such a man was John Evan Davis, Jr.

Memoir of Samuel Creadick Rhoads
i 900— 1 968*

By WARREN S. REESE, m.d.

DR. Samuel Creadick Rhoads died in
Doctors Hospital, Coral Gables,
Florida, on April 10, 1968, after a
long illness. He was born in Philadelphia,
Pa., on September 1, 1900, to John Neely
Rhoads and Anna Driggs Day Rhoads, both
of whom were members of old Colonial
families.

Dr. Rhoads displayed his hardy Colonial
background and "Amor Patriae" when dur-
ing World War I he enlisted in the Army as
a private though still in his teens.

Following discharge from the Army in
1919, he entered Temple University where
he completed pre-medical training and re-
ceived his M.D. in 1926. He interned at
the Montgomery Hospital, Norristown, Pa.,
and then specialized in ophthalmology. On
May 28, 1928, he married Dr. Rebecca Mc-
Farlane, a graduate of Woman's Medical
College.

He was made Assistant Surgeon at the
Wills Eye Hospital in 1927 and in 1930 be-
came Ophthalmologist to the Philadelphia
General Hospital. In 1934 he was appointed
Instructor in Ophthalmology at the Wom-
an's Medical College in Philadelphia, con-
tinuing on the faculty until 1942, becoming
Associate Professor, Acting Professor and
finally Acting Head of the Department of
Ophthalmology.

In 1 942, his Colonial ancestry again mani-
fested itself when he discontinued private
practice, resigned his positions at various
hospitals and clinics to enter the United

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

States Air Force, serving as Captain in the
Medical Corps throughout World War II
and being commended for his performance.

After World War II, Dr. Rhoads resumed
the practice of ophthalmology and his as-
sociation with various hospitals and clinics,
serving as Visiting Ophthalmologist to the
Philadelphia General Hospital, Consulting
Ophthalmologist at Underwood Hospital,
Woodbury, New Jersey, Wills Eye Hospital
and the Woman's Medical College Hospital.

He was a Diplomate of the American
Board of Ophthalmology, a member of the
American Medical Association, the Wills
Eye Hospital Society, the Gloucester County
Medical Society of New Jersey and the Air
Force Association.

Dr. Rhoads was active in the Baronial
Order of Magna Charta, and was serving as
a Surety at the time of his death. He also
held membership in the Sons of the Revolu-
tion, the Huguenot Society, Military Order
of the Crusaders, the LuLu Shrine, the
Union League and the Society of American
Magicians.

His hobbies were golf, cabinet wood work,
and spinning and electroplating of copper.

Dr. Rhoads is survived by his widow and
a son, Dr. John M. Rhoads, presently Pro-
fessor of Psychiatry at Duke University, and
four grandchildren.

Those of us who knew Dr. Rhoads will
remember him as a delightful, retiring, but
nevertheless hard and conscientious worker
who for years assisted, and was much de-
pended upon, by one of the most dexterous
and ingenious Attending Surgeons at the
Wills Eye Hospital, Dr. Frank C. Parker.

176

Memoir of Reuben Lore Sharp
1897-1968*

By THOMAS M.

DR. Reuben Lore Sharp was born in
Mullica Hill, New Jersey, on Aug-
ust 14, 1897. He died on his farm
in Mt. Holly on October 17, 1968.

He attended public schools and matricu-
lated at Dickinson College in Carlisle, Pa.
During his freshman year, his father, who
was a practicing physician in Camden but
who continued to reside with his family on
a large operating farm in Mullica Hill, died.
During this crisis, it was necessary for Dr.
Sharp as the oldest son to leave college and
take over the management of the farm. This
was during World War I. His work on the
farm gave him an automatic draft exemp-
tion. After he operated the farm for three
years, arrangements were made for him to
return to college, where he distinguished
himself both as a student and as an athlete.
Football was his special sport and he played
on the varsity for three years.

Following graduation, he entered the
School of Medicine at the University of
Pennsylvania and then interned at the
Graduate Flospital. Subsequently, he spent
two years as an associate of Dr. Henry
Bockus at the University of Pennsylvania
prior to opening his own offices in Camden.
He was promptly appointed to the Cooper
Hospital Medical Staff and soon after was
certified by the Board of Internal Medicine.
Immediately after Pearl Harbor, he en-

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

KAIN, JR., m.d.

listed in the Naval Medical Corps and was
appointed senior medical officer of the 4th
Division, U.S. Marines. He had a distin-
guished combat record in the South Pacific.
His naval combat duty was a source of great
satisfaction to him because he had a keen
awareness of his duty to his country. In
1946, he was released from active duty, re-
turning to his Camden office and Cooper
Hospital.

Dr. Sharp was former President of the
Camden County Medical Society and for
many years was a trustee of the Medical
Society of the State of New Jersey. He was
former Chief of the Department of Medi-
cine at Cooper Hospital.

Dr. Sharp is survived by his widow, the
former Mary Chambers, and four children.

Dr. Sharp had a large practice, and there
are few among his patients who will ever
forget him. He had an innate ability to in-
spire confidence. He was generally sensitive
to the health of others, and it was always
his wont to subordinate himself to the needs
of the sick people.

His professional colleagues will remember
him as a distinguished internist and gastro-
enterologist. The public will remember him
as the epitome of honesty, unbending in in-
tegrity, and always demanding of himself
that he do the "right" thing as his judgment
dictated.

All of us in the Camden area will miss Dr.
Sharp.

177

Memoir of Calvin Mason Smyth, Jr.
1894-1967*

By TITO AUGUSTINE RANIERI, m.d.

CALVIN MASON SMYTH, JR., was
born in Philadelphia, August 24,
1894, the son of Calvin Mason Smyth
and Margretta Slaughter Smyth. He was
the eldest of four children. His education
was in Philadelphia, where he attended
Germantown Academy, earned a B.S. from
the University of Pennsylvania and was
graduated in the famous Class of 1918 of
the School of Medicine. Many members of
that class attained professorial rank in vari-
ous fields of medicine. His uncle, Henry
Field Smyth, was Professor of Hygiene at
the School of Medicine.

His marriage to Madeline Williams
Smyth brought forth two illustrious sons:
Calvin Mason Smyth, III, of the State De-
partment of the United States, specializing
in the Affairs of Latin America and Far East
Relations, and Thomas Williams Smyth,
Vice President of Smyth, Akins & Lerch.
Both young men were wrestling champions
in the Interacademic League. There are
now five grandchildren in the lineage.

After service in the United States Army
Medical Corps in World War I, he was an
intern and surgical resident at the Hospital
of the University of Pennsylvania under the
Professorship of John B. Deaver. In 1920 he
was appointed Instructor in Surgery at the
Medical School and the same year to the
original faculty of the Graduate School of
Medicine as Instructor in Surgical Research.
He progressed through academic levels to
Professor in 1952 and Emeritus Professor in
1961. In his formative years, he was Profes-
sor of Physiology at the Philadelphia Col-

* Read before The College of Physicians of Phila-
delphia, 9 October 1968. Prepared and published at
the request of the Council of The College of Phy-
sicians of Philadelphia.

lege of Pharmacy. His vast knowledge of the
Polyherbalists was fascinating.

Dr. Smyth was associated with Dr. Damon
B. Pfeiffer and was co-author of many surgi-
cal treatises. He was affiiliated with many
hospitals in the metropolitan area of Phila-
delphia. He served at the Methodist Hos-
pital (1919-1950) as Chief of Surgery (1932-
1950) and at the Woman's Hospital. In
1953, he became Surgeon-in-Chief of the
Abington Memorial Hospital and Director
of the Pfeiffer Clinic, posts from which
he retired in 1963.

He was Consultant in Surgery to the
United States Naval Hospital, Philadelphia,
and a Consultant to the Surgeon General of
the Army. He made a survey of the medical
facilities of the United States Army in
Europe in 1953 and in the Asian Theater of
Operations in 1956. He was retired as Briga-
dier General in the United States Army
Medical Corps Reserve.

He was a member of the Philadelphia
County Medical Society, the Medical Society
of the State of Pennsylvania, the American
Medical Association; a Fellow of the Ameri-
can College of Surgeons, American Surgical
Association, Philadelphia Academy of Sur-
gery, The College of Physicians of Phila-
delphia, Societe Internationale de Chirurgie
(Brussels), American Association of Uni-
versity Professors, Eastern Surgical Associa-
tion and Society for Surgeons of the Ali-
mentary Tract. He was a member of the
Society of the Sigma Xi, Phi Kappa Psi
Fraternity (College) and Phi Alpha Sigma
(Medical), Society of the Friendly Sons of
St. Patrick and Union League of Phila-
delphia.

Dr. Smyth edited many books on surgery,
one a revision of Bickham's Operative Sur-

178

MEMOIR OF CALVIN MASON SMYTH, JR.

179

gery, Vol. VIII, 1932, another Surgical
Treatment, and three volumes by Warbasse,
1937. Also, he was the author of numerous
chapters and many articles in surgical litera-
ture. This work and duties led him directly
to his second consort, Marguerite Schlegel.
He affectionately preferred to call her
Martha who, like the Biblical figure, per-
formed her cheerful chores. This charming
lady prepared the voluminous manuscripts,
and she was his constant companion at meet-
ings, on his tours of duty, lecturing and
examining.

When the American Board of Surgery
was formed in 1937, he was a founder; he
was active in the organization and prepara-
tion of the first examinations. He was closely
associated with Doctor J. Stewart Rodman
in the Secretarial Office and became Vice
Chairman 1951-53. This is important as a
part of the history of surgery in the United
States. The many Diplomates of the Board
who have gone through the rigorous exami-
nations for certification will recall their
state of anxiety. Despite the fact that he
examined more young surgeon candidates
than any other member of the Board, his
great tact and understanding in dealing
with their problems brought admiration for
his unflinching honesty and fairness. His
efforts were a labor of love and he was loyal
to the ideals and objectives of improving
surgical training in the United States.

As a Fellow of the Academy of Surgery,
he was faithful to all its meetings. He was
Secretary for many years and progressed to
every office, culminating as its President
from 1950-52. He stimulated debate and
controversial dialogue. His discussions were
eloquent, well-worded and concise, favoring
constructive criticism. He gave the Annual
Oration on December 4, 1944, entitled,
"Graduate Surgical Training in America."

As a member of the Original Faculty of
the Graduate School, he became the non-
pareil in the transition of teaching to gradu-
ate students in contrast to the undergradu-
ates. The two-hour round table conferences

were well-organized with teacher-student
participation in all phases of the profession.
He emphasized the importance of adhering
to routine in the care of patients regardless
of their social status. While associated with
Dr. Joshua E. Sweet in the Research Depart-
ment, he designed the operating table with
a center trough for experimental surgery on
animals.

Following the attack on Pearl Harbor, the
Surgeon General sent hundreds of neo-
surgeons to the Graduate School. He and his
associates participated without honorarium
in teaching the six-week intensive course.

The early years of the twentieth century
saw a great change in undergraduate educa-
tion, whereas between the two World Wars
growing improvements in graduate medi-
cal education, specialty training and branch
specialties were evolved. It was during this
era that Dr. Smyth and many senior mem-
bers of the Academy were architects in
molding new practice in the decorum of the
profession and a more cordial relationship
in sharing medical and surgical manage-
ment. This was the period in which empha-
sis was placed in making the "patient safe
for surgery." Despite his efforts to insure
that the Science and the Art of Surgery ad-
just to the changes in social relationship, he
kept the common touch. It was a pleasure to
watch a skillful and merciful surgeon exam-
ine and gently palpate the abdomen of an
acutely ill patient.

In 1935, he was the medical consultant for
the Compensation Labor Laws of the State
of Pennsylvania which brought uniformity
in compliance with disability in line of duty
for the laborer. In 1955, Governor George
Leader appointed Dr. Smyth as the first
M.D. to the State Board of Examiners of
Osteopathic Physicians. He accepted the as-
signment not for disparagement but to shed
enlightenment in this competitive profes-
sion. He organized the modus operandi of
the examinations and raised the standards
of the future practicing physicians.

In his youth, he was associated on the

180

TITO AUGUSTINE RANIERI

stage with Edward Everett Horton and
William Harrigan with whom he developed
lifelong friendships. In college he was cox-
swain of the varsity crew and an accom-
plished bass-violinist. He proudly displayed
his active Local 77 Musicians Union Card.
He was a masterful raconteur which en-
deared him to many friends. He was the
stellar attraction at the Annual Meeting be-
tween the New York and Philadelphia Sur-
geons. He had the highest faculty of the
intellect and the finest medium for com-
munication.

His death on June 18, 1967, was due to

the "physician's malady," an acute myo-
cardial infarction and its sequelae.

He led a full life as he was devoted to his
work and his scientific accomplishments.
Yet he enjoyed the pleasures of life: good
company, music and conversation. He was
a great teacher, an investigator of merit and
a clinical surgeon with skill, sympathy, and
warmth toward patients.

The dead live in the memory of the liv-
ing. Dr. Smyth as a believer of body and soul
left us the heritage: Live and be prepared to
die tomorrow; work and learn as to live
forever.

Transactions of the Philadelphia
Neurological Society

OFFICERS 1969
President
Frank A. Elliott, M.D.

1st Vice President 2nd Vice President

Henry T. Wycis, M.D. William S. Masland, M.D.

Secretary Treasurer
Lawrence C. McHenry, Jr., M.D. Martin Mandel, M.D.

Editor
Julina Gylfe, M.D.

PROGRAMS 1968-69*

October 4, 1968

Dedicated to the Memory of
G. Milton Shy, M.D.

Memorial to G. Milton Shy, M.D.

GUNTER HAASE, M.D.

DISEASES OF MUSCLE
Degeneration and Regeneration of Muscle.

Henry Schutta, m.d.
Type I Muscle Fiber Hypotrophy with Central

Nuclei. W. King Engel, m.d. and D. C.

De Vivo

Glycogen Storage Diseases of Muscles. Lewis P.
Rowland, m.d.

Memorial to G. Milton Shy, M.D.

GUNTER HAASE, M.D.

Dr. Moore, members and guests of the Society:
Mrs. Shy has asked me to convey her thanks
* Published by the Transactions & Studies of The

College of Physicians of Philadelphia, Vol. 37, No.

2 (4th Series), October 1969. Waverly Press, Inc.

Baltimore, Maryland 21202.

Abstracts received by the editor after 15 July 1969

are published by title only.

Reprints: Julina Gylfe, M.D., Editor, 1315 DeKalb

Street, Xorristown, Pennsylvania 19401.

to the Philadelphia Neurological Society for
dedicating this meeting to die memory of her
husband, Dr. G. Milton Shy. She and her chil-
dren, Michael and Kathy, have further asked
me to bring you their warm wishes for a suc-
cessful meeting.

Milton Shy was a scholarly man. His con-
tributions, as an investigator, are well known.
In the short span of years he was allotted in
his profession, he gained respect in diis coun-
try and abroad. The secmence of his appoint-
ments is testimony to his abilities, as the affec-
tion of his friends is testimony to his character.

He was a dedicated and ambitious man. Re-
sponsibilities came to Milton early. At 32, fresh
from his training in London and Montreal,
he became Chief of Neurology at the University
of Colorado. There was the beginning of his
great attractiveness as a teacher. His lectures,
on Thursday evenings, were among the best-
attended teaching activities of the school. Two
years later, at 34, Milton accepted the awesome
position of Clinical Director of the National
Institute of Neurological Diseases and Blind-
ness. If he felt diffidence, he did not show it.
He did not see mountains as obstacles but as
peaks to be conquered. His enthusiasm and his
dedication were covenants with success.

181

182

PHILADELPHIA NEUROLOGICAL SOCIETY

He was a complex man. His loyalties were
strong, and equally strong were the loyalties his
associates and students offered him. His wish
to bring out the best in his pupils could, at
times, be costly to their sensitivity. Yet, I think
he was happiest at his rounds and teaching
conferences. Here, he could bring to bear not
only his rich clinical knowledge, but also die
understanding he had gained of the basic sci-
ences, and if he became convinced that an area
of the basic sciences was relevant to his labors,
he set out to master it, and master it he would.

His intensity of purpose was softened by his
warmth, his friendship, and by a streak of mis-
chief. Here was a man whose office walls were
covered by the foreboding pictures of great
men, great places, diagrams of complex meta-
bolic pathways — and by a well used dartboard.
As was said of Anthony, "His delights were
dolphin-like, they showed his back above the
element they lived in" — so we remember George
Milton Shy.

Degeneration and Regeneration of Muscle
Henry Schutta, m.d.

Biopsies from patients with paroxysmal idio-
pathic myoglobinuria revealed transverse ne-
crosis of myofibers, where there is destruction
of the plasma membrane and subsequent inva-
sion of the damaged fiber by phagocytes. Cen-
tral necrosis, where damage is confined to cen-
tral areas of the myofiber and does not reach
the plasma membrane, gives rise to necrotic
vacuoles which are similar to those found in
other vacuolar myopathies. In the past, these
vacuoles have been interpreted as dilatations
of the sarcoplasmic reticulum. This interpreta-
tion appears to be incorrect since the mem-
brane bounding the vacuoles is related to the
T-system, and progression from central necrosis
to vacuoles can be discerned in the biopsies.
In acute states, bulbous dilatations of the T-
system give rise to smaller vacuoles, and these
are thought to reflet electrolyte disturbance in
partially damaged muscle. Evidence of regen-
eration was present in myofibers with trans-
verse necrosis, where regenerant cell processes
were present at the periphery of the myofiber.
It is not certain whether they arise from normal
parts of the damaged myofiber or whether they
represent activated satellite cells. These find-
ings were compared with degenerative changes

and vacuolar abnormalities in a case of hy-
pokalemic periodic paralysis.

Type I Muscle Fiber Hypotrophy with
Central Nuclei
W. King Engel, m.d.
D. C. De Vivo

A 12-year-old boy with congenital muscle
weakness was found by histochemistry of his
muscle biopsy to have type I muscle fiber hy-
potrophy with central nuclei. Details of his
clinical findings, as well as histochemical and
electro-microscopic studies of his muscle biopsy,
were presented. A comparison was made with
experimental attempts to reproduce this condi-
tion. The pathogenesis was speculated upon in
the light of current information on the signifi-
cance of histochemical types of muscle fibers.

Glycogen Storage Diseases of Muscle
Lewis P. Rowland, m.d.

The glycogen storage diseases are rare but
important beyond their numbers, for they are
the first inherited diseases of muscle in which
die biochemical abnormality is known. Because
the symptoms differ depending upon which en-
zyme is deficient, these diseases provide infor-
mation about the functional importance of
different steps of the metabolic pathway. Im-
portant problems remain, however. The precise
relationship between the biochemical abnormal-
ity and symptoms has been difficult to eluci-
date. Atypical syndromes associated with specific
enzymatic defects have been found, and in some
cases more than one enzyme seems to be af-
fected. This review attempted to elucidate the
significances of these problems.

November 1, 1968

CLINICAL CASE REPORTS

Cerebral Aneurysm Following Spontaneous Ca-
rotid Occlusion. Marvin E. Jaffe, m.d.
and Lawrence C. McHenry, Jr., m.d.

Respiratory Arrest from Seizure Discharges in
the Limbic System. Dewey A. Nelson
m.d. and Charles D. Ray, m.d.

Prevention of Post-herpetic Neuralgia. Frank
A. Elliott, m.d.

Management of Brain Swelling Through Con-

PROGRAMS 1968-1969

183

tinuous Recording of Intracranial Pressure.
T. W. Lancfitt, m.d., N. F. Kassell, m.d.
and S. S. Lyness, m.d.

Cerebral Aneurysm Following Spontaneous
Carotid Occlusion
Marvin E. Jaffe, m.d.
Lawrence C. McHenry, Jr., m.d.

Cerebral aneurysms have been noted to en-
large, and new cerebral aneurysms to occur,
subsequent to carotid artery ligation as a treat-

I ment for aneurysms. However, symptomatic
, cerebral aneurysm formation is not a reported
: complication of spontaneous or atherosclerotic

carotid artery occlusive disease, nor has it been
i reported as a significant accompaniment of ad-
• vanced cerebrovascular disease. This is not due
to failure to search for them, since our group
and many others as well have done large num-
bers of angiograms in individuals with carotid
; artery occlusive disease.

A case is reported of a 79-year-old Negro fe-
. male who developed a symptomatic right in-
i ternal artery aneurysm 10 years after suffering
a stroke due to a left internal carotid artery
occlusion. She subsequently died of an acute
subarachnoid hemorrhage.

We presented this case as both the first re-
ported symptomatic carotid artery aneurysm af-
ter spontaneous carotid artery occlusion, and
. also for the value it has in pointing out the
likelihood that developmental vascular anom-
alies rather than acquired degenerative changes
are the substrate upon which saccular aneu-
rysms occur. Hydraulic and hemodynamic fac-
tors alone are insufficient to cause aneurysms.

Respiratory Arrest from Seizure Discharges
in the Limbic System
Dewey A. Nelson, m.d. and
Charles D. Ray, m.d.

Since 1899, when Hughlings Jackson first de-
scribed respiratory arrest as part of an un-
cinate fit, a large body of experimental evidence
has shown that respiratory arrest occurs when
a number of structures in the cerebral hem-
isphere are stimulated. The respiratory arrest

I I is usually in expiration and occurs when the
following structures are stimulated: posterior

I lateral frontal cortex, inferior medial temporal
cortex, anterior insular cortex, anterior cingu-

late gyrus, amygdala, uncus and fornix. The
longest reported respiratory arrest from cortical
stimulation, to date, has been for 56 seconds.

A depth probe stimulation study was per-
formed on a 13-year-old girl, who from the age
of seven had uncontrolled generalized and psy-
chomotor seizures. One depth stimulation study
revealed rhythmic 20 to 40 second after-dis-
charges when a narrow 6 mm. zone near the
center of the left amygdaloid nucleus was stim-
ulated. Arrest occurred in inspiration when the
stimuli were applied at the height of inspiration;
similarly, stimulation at the height of expira-
tion produced expiratory arrest.

A second patient, a 50-year-old physician,
developed generalized and temporal lobe seiz-
ures at the age of 20. At the age of 12, he suf-
fered an electrical shock injury, wherein the
current entered the body through the right
thumb and exited dirough the left temporal
region. The patient has an EEG spike focus in
the left mid-temporal region. The patient was
found cyanotic and apneic in bed at home, after
he had gotten into bed because of feelings of
extreme fatigue. Several interesting EEG trac-
ings were made during these periods of apnea.
One of these revealed a low voltage tracing
with spindle-like forms of 6 to 14 per second
frequency. Another revealed a slow, disorga-
nized tracing with sharp wave discharges em-
anating from a wide region over the left fronto-
temporal region. Because of a history of tem-
poral lobe injury and of psychomotor seizures,
and because these episodes of arrest cannot be
ascribed to a prolonged convulsion with mus-
cular exhaustion, or to the ingestion of some
drug, we have concluded that these respiratory
arrests represent some type of seizure phe-
nomenon. There are several reservations about
this hypothesis: 1., Experimental stimulation of
limbic structures has produced arrest for only
a minute or less whereas this patient has been
in arrest up to 30 hours; 2., Delayed brain stem
lesions from electrical shock injury are known
to occur; 3., There are no clinical reports of
similar type to confirm these observations.

Prevention of Post-herpetic Neuralgia
Frank A. Elliott, m.d.

Post-herpetic neuralgia has been reported to
occur in 30% of patients over 40 and in 50%
of patients over 60. By contrast, post-herpetic

184

PHILADELPHIA NEUROLOGICAL SOCIETY

neuralgia did not occur at all in 64 personal
cases of shingles treated by the administration
of high doses of prednisone within the first
seven days of the appearance of the rash. The
average age of the group was 64 years. The
facial paralysis of geniculate herpes recovered
in two to three weeks. Controls fared less well.
The treatment, its rationale, and its complica-
tions were discussed.

Management of Braiti Swelling through Contin-
uous Recording of Intracranial Pressure
T. W. Lancfitt, m.d., N. F. Kassell, m.d.

AND S. S. LYNESS, M.D.

Cerebral swelling is a common cause of death
following head injury, cerebrovascular accidents,
and intracranial surgery. The primary aim of
treatment (hypertonic solutions, hypothermia,
steroids, hyperventilation) is to reduce brain
bulk. The only reliable criterion for estimating
the degree of brain swelling and the result of
therapy is intracranial pressure. We have re-
corded intracranial pressure continuously fol-
lowing craniotomy in 85 patients. A catheter was
inserted into the subdural space at the comple-
tion of the operation and attached to a trans-
ducer and polygraph in the Intensive Care
Unit. The earliest sign of cerebral swelling is
a gradual rise in intracranial pressure and, of
equal importance, fluctuations in intracranial
tension from normal to values as high as 60
to 80 mm. Hg. These pressure waves are char-
acteristic of brain swelling and intracranial
hypertension, irrespective of the cause. Clinical
signs at the peak of the pressure wave include
headache, vomiting, and increased neurologi-
cal deficit, but frequently there is no change
in the patient's clinical status. Between pres-
sure waves, intracranial tension remains ele-
vated, and, ultimately, a terminal pressure
wave occurs. Intracranial pressure rises to die
level of the blood pressure and cerebral blood
flow is abolished. The terminal pressure wave
is a common cause of rapid deterioration and
deadi in patients with a space-occupying lesion
or brain swelling. Miniature, solid-state trans-
ducers are now available for measurement of
intracranial pressure. A small transducer can
be inserted into the intracranial space through
a twist drill hole in the skull, in order to moni-
tor patients with severe head injury and strokes,

and the procedure can be carried out in the

Emergency Ward.

December 13, 1968

THE BORDERLAND OF NEUROLOGY
AND PSYCHIATRY

Electrophysiologic Studies of Mental Disorder.
Charles Shagass, m.d.

Neuropharmacology of Hallucinogenic Drugs.
Georce B. Koelle, m.d.

Some Thoughts on the Limbic System. Joel
Elkes, m.d.

Electrophysiological Studies of Mental Disorder
Charles Shagass, m.d.

The idea that deviant neurophysiology must
meditate deviant behavior is generally accepted,
but psychiatrically relevant neurophysiological
indicators have been hard to define. EEG find-
ings in "functional" mental disorders have been
disappointing, although cautious optimism is
being generated by approaches applying com-
puter methods. The technique of recording
sensory evoked responses by "averaging" has
also yielded encouraging results in recent years.

This presentation reviewed some of the main
findings obtained in our research program
which, for nearly a decade, has attempted to
establish psychiatric correlates of evoked re-
sponse characteristics. As data have accumulated,
it has become clear that many factors, such as
age, sex, drugs, and state of alertness, can in-
fluence evoked responses. Inconsistent results
are probably attributable to imperfect control
over such factors. One finding has been con-
sistent in our own studies and those of odiers:
recovery function, as measured by applying
paired "conditioning" and "test" stimuli, is
reduced in psychiatric patients. Furthermore,
in current studies, we are finding that the
orderly relationship between "conditioning"
stimulus intensity and "test" responsiveness
present in normals is virtually absent in most
schizophrenic patients. This suggests disordered
balance between "inhibitory" and "facilitatory"
processes in die patients.

Another new area of considerable interest
concerns EEG-evoked response relationships
and their behavioral correlates. We have re-

PROGRAMS 1968-1969

185

cently found that superior perceptual perform-
ance is associated with greater EEG-evoked
response amplitude concordance. Psychopadio-
logical correlates of such concordance variability
are being investigated.

Neuropharmacology of Hallucinogenic Drugs
George B. Koeixe, m.d.

Hallucinogenic drugs probably act primarily
in sites of the subcortical limbic system to pro-
duce their characteristic effects of hallucina-
tions, diffuse anxiety, and sympathetic hyper-
; tonia. It is likely that they do so by modifying
synaptic transmission through adrenergic or
serotoninergic padiways at these levels. Of pri-
mary interest is the possible relationship of
the actions of the hallucinogenic agents to bio-
chemical abnormalities in the etiology of natu-
rally occurring psychoses.

February 7, 1969
NEURORADIOLOGY AND BLUSHING

Tumor and Blushes. Mark M. Mishkin, m.d.

Inflammatory Diseases and Blushes. Norman
Leeds, m.d.

Occlusive Disease and Blushes. Herbert Gold-
berg, m.d.

Tumor and Blushes
Mark M. Mishkin, m.d.

Serial angiography in at least the AP and
lateral projections is necessary in order to eval-
uate and differentiate various types of tumors.
With good quality angiography, correct predic-
tion of histologic types of vascular tumors
should be achievable as often as 75% of the
time. Differentiation of benign from malignant
lesions is achievable more often than that.

Vascular lesions fall into four groups: 1.,
meningioma; 2., astrocytoma grades III or IV;
3., metastasis, and 4., other. The general charac-
teristics of a vascular tumor are divided into
two major categories: a., morphologic and b.,
dynamic. Under morphology we find 1., en-
larged afferent arteries; 2., neovasculature; 3.,
"blush" or "stain"; 4., enlarged and/or early
filling veins. Under the dynamic characteristics
are 1., faster circulation through the tumor —

usually malignant; 2., normal circulation — usu-
ally benign.

Meningiomas are usually highly vascular, hav-
ing a double blood supply from the internal
and external carotid system, which is pathog-
nomonic. Characteristically the vessels are seen
to radiate from a bony point.

In those tumors demonstrating rapid flow of
blood into die venous circulation we can make
a diagnosis of malignancy, either glioma or
metastasis. These tumors more often drain into
the deep veins. Gliomas need not be space-tak-
ing even when they are highly vascular. Oc-
casionally the grade II astrocytoma can be
diagnosed because of its entrapment of vessels
supplying it, these vessels sometimes being en-
larged even though no tumor stain or early fill-
ing vein is present.

The metastases also demonstrate rapid flow.
The tumor stain starts a little later and fades
more quickly. Obviously the presence of multi-
ple lesions makes tliis diagnosis more definite.
Unfortunately, it is not unusual for metastasis
to be indistinguishable from gliomas.

In the posterior fossa, two highly vascular
and usually benign lesions are present. These
are the cerebellar hemangioblastoma and the
chemodectoma. Both of drese show very rapid
venous shunting as well as an intense tumor
stain. The hemangioblastoma is not infrequently
cystic with a mural nodule representing the
highly vascular component.

Differentiation from arteriovenous malforma-
tions can at times be difficult since the dynamics
are similar to that of a malignant tumor.
However, the arteriovenous malformation lacks
the disorganized neovasculature of the glioma
and is often nqn-space-taking since it is fre-
quently accompanied by focal atrophy sec-
ondary to the shunting and resultant "steal."

Inflammatory Diseases and Blushes
Norman Leeds, m.d.

In a review of 27 patients with inflammatory
diseases of the brain, hypervascular patterns
were observed in 12. There are three different
causes for the hypervascular patterns. In the
first group, the blush is a result of loss of auto-
regulation with anoxic vasodilatation of arteries
at the margins of the lesion and shunting of
blood with early filling of the veins. The veins
filled are the normal veins in the area. This

186

PHILADELPHIA NEUROLOGICAL SOCIETY

type of abnormal vascular pattern is observed
at the periphery of the lesion and occurred
in five patients.

The second abnormal pattern is a blush
seen about the margin of the lesion in four
patients and represents neovascularization
within die capsule about an abscess. The blush
is non-uniform, homogenous, circumscribes the
lesion, and is of long duration persisting from
the late arterial through the venous phase. This
should be distinguished from a pseudocapsule
which may be seen in abscesses and actually
represents compression of brain tissue by the
mass. This type of blush is not uniform, less
homogenous, and of short duration.

The third type of abnormal vascular pattern
is tint observed secondary to a reactive hypere-
mia that develops locally in the brain as a re-
sponse to an inflammatory lesion. In two pa-
tients, there was vasodilation of large arteries
supplying the area of involvement and in one of
these patients there was a transient blush with
prominent draining veins. In the other patient,
there was premature filling of subcortical tem-
poral veins. In die third patient, vasodilatation
of arterioles as well as capillary vasodilatation
was observed. This small vessel dilatation ac-
counted for the vascular blush observed. These
three patients all had varieties of encephalitis.

Occlusive Disease and Blushes
Herbert Goldberg, m.d.

The hyperemic blush observed in many pa-
tients following a cerebral infarction is re-
lated to a loss of normal autoregulation in and
around the damaged area of the brain. With
autoregulation abolished in drese regions, the
normal vasoconstrictor tone is lost in the arteri-
olar bed. This results in a reduction in the
local vascular resistance and generally a higher
flow through this vascular bed, as long as the
local arteriolar pressure head is not reduced
due to occlusion of the supplying artery. Angio-
graphically, this pathophysiological alteration in
local cerebral hemodynamics is evidenced by a
greater volume of contrast passing rapidly
through die brain tissue into early-appearing
normal regional veins. The hyperemia is located
throughout the infarcted area when there is
adequate primary or collateral circulation pres-
ent. It is located on the periphery if the in-

farcted tissue remains ischemic at the time of
angiography.

The angiographic characteristics of die blush
consist of I., its localization primarily within
the cortex, 2., a punctate arteriolar dilatation,
3., a uniform capillary cortical stain, 4., a rapid
disappearance of the blush with early filling of
normal regional veins. The blush may be local-
ized to a single convolution or may be more
extensive, covering die entire vascular distribu-
tion of a major cerebral branch. Very frequently,
no occlusions are demonstrated which may be
due to either a previous embolic thrombus,
which has dissolved, or secondary to an hypoxic
episode from a period of relative or absolute
hypotension in a hypertensive patient with
cardiovascular disease.

The blush generally does not persist for more
than 2 to 3 weeks following the infarction be-
cause autoregulation returns in the damaged
areas. Follow-up angiography after two weeks
will reveal either complete clearing or a marked
resolution in the hyperemic reaction when it is
secondary to loss of autoregulation following
cerebral infarction.

March 7, 1969

THE INFLUENCE OF NOXIOUS AGENTS
ON THE DEVELOPING NERVOUS
SYSTEM

The Influence of Malnutrition on the Develop-
ing Nervous System. Donald J. Fishman,
m.d.

Studies on Genetic Acid Mucopolysaccharidosis,
Type 3. M. Harold Fogelson, m.d.

Calcium Exchange between Blood, Brain, and
CSF. Leonard J. Graziani, m.d.

Metabolic Abnormalities in Subacute Necrotiz-
ing Encephalomyelitis. Warren Grover,

M.D.

Studies on Genetic Acid Mucopolysaccharidosis,
Type 3
M. Harold Fogelson, m.d.

The Genetic Mucopolysaccharidoses (genetic
MPS) are inherited disorders of connective
tissues associated with increased tissue accumu-
lation and urinary excretion of acid glycos-

PROGRAMS 1968-1969

187

aminolycan (GAG — acid mucopolysaccliarides).
Currently, there are six types separated by clini-
cal, genetic, radiographic and biochemical evi-
dence. All disorders are inherited as autosomal
recessive traits except MPS II, which is inherited
as an X-linked recessive trait.

MPS I or Hunter's Disease is the prototype
disorder whose features are seen in a variable
extent in the other disorders. MPS II or Hun-
ter's Disease differs from MPS I in having no
corneal opacities and less rapid deterioration
of mental and physical abilities.

Type III MPS or Sanfilippo Disease was de-
scribed in 1963 for a group of children whose
gross features are reminiscent of the other types
but whose somatic changes arc minor in com-
parison to the severe degree of mental retarda-
tion. These children have slightly retarded
development early but learning plateaus by 3
years. They almost never achieve speech; those
milestones diat are gained are subsequently lost.
Their behavior deteriorates and the children be-
come withdrawn, stubborn and excessively
sleepy.

Physical examination demonstrates little:
corneas are clear; joint restriction is minimal;
hepatosplenomegaly is not consistently found;
no cardiac problems have been noted; head is
scaphocephaly and large with frontal bossing
in late stages; neurological examination elicits
increased tendon reflexes and abnormalities of
movement — suggesting athetosis. Seizures are
frequent. Death occurs by die end of the second
decade due to increased neurological deteriora-
tion, inanition and pneumonia.

Urinary findings have revealed increased
quantities of glycosaminolycan — specifically hep-
aran sulfate widi lesser quantities of Dermatan
Sulfate (Chondroitin sulfate B). As with other
genetic MPS, bone changes are usually pro-
nounced in those disorders excreting Dermatan
sulfate, while mental retardation occurs in those
disorders excreting heparan sulfate as a major
GAG.

We recently have been attempting to modify
urinary excretion of GAG in Sanfilippo patients
by salicylates. Among its functions, salicylates
interfere with PAPS sulfation and have been
shown to retard organization of connective
tissue in its final form. In three patients who
were discovered at a late stage, that is, after
two years when changes had already proceeded

at an inexorable rate, we administered salicyl-
ates in doses of 100 mgm./kg. — a similar range
to that used on rheumatic fever patients. Our
results suggest that there occurs a twofold in-
crease of urinary acidic (. U. excretion on short
term administration of 7 days. This increased
excretion was not on die basis of renal creatinine
clearance, which remained constant.

Calcium Exchange between Blood, Brain,
and CSF
Leonard J. Graziani, m.d.

Toxic effects of altered serum calcium con-
centrations on die central nervous system have
been noted in infants, children and adults.
Animal experiments have demonstrated pro-
found behavioral effects with changes in the CSF
concentration of calcium, related to altered
electrical excitability of nervous tissue. In addi-
tion, the calcium level in the CSF tends to re-
main within a limited range, independent of
the level in the serum, and the normal CSF to
serum ratio of approximately 0.5 is not main-
tained in man or dog with hypo- or hyper-
calcemia.

In acute experiments, calcium exchange was
measured in anesdietized cats during steady-
state ventriculocisternal perfusions. When Ca 45
was added to the perfusate, the efflux coefficient
was independent of CSF Ca concentration, in-
dicating passive diffusion. About one-third of
this isotope was recovered in brain tissue and
was localized to areas immediately adjacent to
the CSF pathway. When Ca 15 was given intra-
venously during ventriculocisternal perfusion, a
component of the influx coefficient from blood
was reciprocally related to serum calcium con-
centration consistent with an active or carrier-
mediated process; another smaller component of
the coefficient was constant, consistent with
passive diffusion.

When oubain was added to the perfusate, both
CSF production and Ca influx was reduced,
suggesting an influx component related to CSF
formation. However, when Diamox was added
to the perfusate, a component of Ca influx con-
tinued independent of the reduced CSF forma-
tion. About one-third of the Ca entering CSF
was from adjacent brain. In hypoparathyroid
animals influx of Ca 4= from blood to CSF was
reduced to about one-half that of normal ani-
mals due to a decreased active component, al-

188

PHILADELPHIA NEUROLOGICAL SOCIETY

though Ca influx from brain to CSF was un-
changed. Ca 46 uptake by brain in cats and
immature and adult rats indicates that the rate
of calcium exchange between blood and brain is
much less than between blood and CSF and is
related to maturity, animal species, region of
the brain and blood calcium concentration.

Metabolic Abnormalities in Subacute Necrotiz-
ing Encephalomyelitis

Warren Grover, m.d.

The clinical and biochemical abnormalities
in a patient with subacute necrotizing encephal-
omyelitis were serially evaluated after a sibling
expired with the same disorder. The appearance
of fundal abnormalities as well as lactic acidosis
were noted before the development of signifi-
cant clinical involvement. In contrast to previ-
ous enzyme assays, higher levels of pyruvate,
carboxylase, and phosphoenolpyruvate carbox-
ykinase levels were found. A review of the
available literature, as well as evaluation of the
second patient, suggests that this syndrome may
result from impairment of more than one
enzyme site in glycolytic pathways.

May 9, 1969

CURRENT DEVELOPMENTS IN THE
TREATMENT OF PARKINSON'S
DISEASE

I. Biocliemistry of Parkinsonism. Stanley Fahn,

M.D.

1 1 . L-Dopa and Parkinson's Disease.

A. Experiences in Treatment of Parkinsonism.

Gabriel A. Schwarz, m.d. and Lewis
P. Rowland, m.d.

B. A Clinical Trial. Edgar J. Ken yon, m.d.,

Richard A. Chambers, m.d. and
Leonard Katz, m.d.

C. Evaluation of 38 Treated Patients. Jack O.

Greenberg, m.d.

III. Role of L-Dopa in the Surgical Treatment of
Parkinson's Disease. Henry T. Wycis, m.d.,
E. Spiegel, m.d., G. Kalett, m.d. and
W. Cunningham, m.d.

Biochemistry of Parkinsonism
Stanley Fahn, m.d.

The use of L-Dopa (L-3,4-dihydroxyphenyl-
alanine) in the treatment of Parkinson's disease
is a classical example of a direct therapeutic
benefit derived from the study of basic neuro-
chemistry, rather than an empirical discovery
of a new drug. The historical aspects of the
scientific discoveries in this area were reviewed.
Also discussed were the metabolism and function
of dopamine in the basal ganglia. The relation-
ship between degeneration of the substantia
nigra and the reduction of dopamine in the
neostriatum can be explained on the basis of a
dopaminergic nigro-neostriatal pathway. The
evidence supporting the existence of this path
and the evidence that reduction of dopamine is
responsible for many of the clinical features of
parkinsonism were also examined.

After more dian 150 years after James Par-
kinson's original description of this disease, we
are now beginning to unravel some of its mys-
tery. Neuropathological studies and experi-
mental lesions in animals left out many pieces
of the puzzle which the chemists and physiol-
ogists are filling in. An interesting sideline of
Dopa therapy is the recognition of the role of
dopamine in the production of choreiform
movements. The role of Dopa, anticholinergics
and phenothiazines in the treatment or causa-
tion of parkinsonism and chorea can possibly
be explained on the basis of transmitter action
on striatal neurons. Despite these recent ad-
vances the loss of pigment, neuronal degenera-
tion and the presence of Lewy bodies in the
substantia nigra are not yet understood.

Experiences in Treatment of Parkinsonism

Gabriel A. Schwarz, m.d. and Lewis P.
Rowland, m.d.

This report was limited to results with our
first 36 patients who had an "adequate" dosage
of L-Dopa for more than one month. We have
accepted any patient in whom the diagnosis of
parkinsonism has been made. Consequently,
many of our patients have been severely in-
capacitated and bedfast, demented, or ill with
disturbances of other systems. A number of our
patients have had various kinds of surgical
procedures for relief of parkinsonism symptoms.

Age at onset of parkinsonism ranged from 32

PROGRAMS 1968-1969

189

to 76 years. Age at start of treatment with L-
Dopa was from 38 to 80 years. Only 9 of our pa-
tients were under 55; while 14 were over 70
years of age. Twenty-five patients had the dis-
ease between 1-5 years; 15 between 5-10; 6 be-
tween 10-15 years and 4 between 15-20 years.
Of our first 51 patients, 3 stopped L-Dopa. One
stopped because of the development of a rash,
lethargy, tachycardia, nausea, and malaise; one

I could not afford to continue; and one had no
improvement at safe dosage.

Results of treatment with L-Dopa (36 pa-
tients): in 2, the disease progressed; in 4, no

, change; 2, slight improvement; 9, significant
improvement; 11, marked improvement; 8,

, return to normal or almost normal. Four of
our patients have died, all because of respiratory
complications associated with dysphagia.

Five to 21 grams of L-Dopa per day have been
used. In general, dosages of more than 8 grams
per day induced postural hypotension and/or
psychoses so that this dosage could not be
maintained. Nineteen of our 36 patients re-
quired 6 grams or less.

Maintenance dosage was less than 7.5 grams
per day in all patients. One patient could not
tolerate any L-Dopa. Most patients required
4 grams per day before any improvement was
perceived. A few patients showed persistent

: gains with remarkably small amounts of L-Dopa
per day.

, Stage of disease, degree of dysphagia, tremor,
rigidity, or ability to arise from a chair, walking
difficulty, hand agility, or postural stability

. were found not to correlate well with die degree
of improvement that occurred. There has de-
veloped an impression that die presence of
dysphagia is an unfavorable sign for therapeutic
response and possibly life expectancy.

None of our patients showed changes in
blood counts or special blood studies (BUN,

I FBS, SGOT, SGPT, alk. phos., PBI). Most
frequent side effects were gastrointestinal upsets
— nausea, vomiting, anorexia; next was chorea;

i \ then orthostatic hypotension; and finally psychic

I or emotional effects. All of the side effects were
temporary and reversible. They promptly cleared
when L-Dopa was stopped or reduced. Invari-
ably, a careful slow increase in dosage avoided
a recurrence of side effects. It was our impres-
sion that the patients who displayed most benefit
i from L-Dopa developed chorea as a side effect.

A Clinical Trail
Edgar Kenton, m.d.
Richard A. Chambers, m.d.
Leonard Katz, m.d.

A double-blind evaluation of L-3,4 dihydroxy-
phenylalanine (L-Dopa) is currently being con-
ducted in 20 patients widi Parkinson's disease.
An additional 10 patients with this disease have
been started (non-double-blind) on this drug.
Of the 30 patients, to date 21 have been com-
pleted of which 9 have shown a dramatic im-
provement; 3, a marked improvement; 8, a
modest improvement, and 1 patient, a marked
worsening of parkinsonism.

Side effects noted to date are nausea, vomiting,
orthostatic hypotension, leukopenia, hypomania
and hyperosmia. In addition, hyperkinesias in
die form of dystonia, choreo-athetosis and
grimacing movements have been observed.

Evaluation of 38 Treated Patients
Jack O. Greenberg, m.d.

The results of treatment widi L-Dopa were
evaluated in 38 patients referred to the Epis-
copal Hospital with a diagnosis of Parkinson's
disease from October, 1968, through March,
1969. Eight patients were markedly improved
and able to perform all functions of daily
living. Thirteen patients showed an excellent
response and were able to perform all functions
of daily living but still had some signs of Par-
kinson's disease. Three of these had to be taken
off the drug for one reason or another. Seven
patients showed a good response with improve-
ment in daily functions but still showing obvious
signs of Parkinson's disease. One of these pa-
tients had to be taken off the drug later. Three
patients had a fair response with minimal im-
provement in functioning and obvious signs of
Parkinson's disease. Two of these had to come
off the drug later. Seven patients never showed
any response.

Side effects were present in a number of pa-
tients. Six demonstrated orthostatic hypotension,
and of these, only one complained of symptoms
upon standing. Nausea was present in 24 pa-
tients, vomiting in 14, chorea in 17 patients, and
in 6 of these the limbs were involved and in 1 1
the mouth was involved with chewing move-
ments. Four patients complained of dizziness or
lighdieadedness and 14 had episodes of con-

190

PHILADELPHIA NEUROLOGICAL SOCIETY

fusion. Eleven patients had hallucinations or
"bad dreams," five became depressed, 4 were
anorexic, and 2 developed incessant talking.

At the time of discharge, the majority of pa-
tients were taking between 8 and 12 capsules a
day. At least three patients improved after dis-
charge from the hospital. Most of the side-effects
were dose-related and were transitory in nature.
At the time of the report, no patient still on the
drug had had any serious lasting side-effects.

Role of L-Dopa in the Surgical Treatment of
Parkinson's Disease
Henry T. Wycis, m.d., E. Spiegel, m.d., G.
Kalett, m.d. and W. Cunningham, m.d.

It is well known that relief of bradykinesia or
akinesia associated with or without rigidity and
with or without tremor by stereotaxic surgery
has not been forthcoming. A previous publica-
tion dealing with an attempt to ameliorate this
distressing symptom by placing stereotaxic le-
sions in the caudate nucleus in six cases resulted
in partial relief in two and a more lasting
result in a third case. The introduction of L-
Dopa has offered a useful pharmacological ap-

proach for the treatment of this disabling feature
of Parkinson's disease. Since there is a diversity
of opinion regarding the effects of L-Dopa upon
tremor, it was decided to treat two groups of pa-
tients (total 30 patients).

Group I were those who were surgically re-
lieved of tremor without any demonstrable
change of their akinesia; and Group II, non-
surgical patients with akinesia or bradykinesia
with rigidity and tremor. All patients were
hospitalized and were treated with L-Dopa, 4-8
grams daily. Blood counts, blood sugars, BUN's,
partial liver profiles, and EKG's were performed
on admission, at one week, and three weeks
later at the time of discharge. The gait, the
speed of flexor-extensor movements of the
fingers and severity and rate of tremor rhythm
as well as tests requiring speed and dexterity
were filmed for exact time intervals before and
after L-Dopa. Toxicity and side effects were
filmed for exact time intervals before and after
L-Dopa. Toxicity and the side effects were re-
corded. The result in both groups were com-
pared and were briefly illustrated by a short
film clip.

EDITOR'S NOTE

Two errors appeared in connection with the Memoirs published in the July
1959 (Vol. 37, No. 1) issue of the Transactions & Studies.

The memoir of John Arthur Daugherty (1902-1968) was prepared by Allen
W. Cowley, Sr., not by Edward C. Raffensperger, as printed, or by Victor C.
Vaughan, III, as listed in the Contents. The memoir with its correct author is
republished in this issue.

The author of the memoir of Joseph Howard Cloud (1872-1968) was Victor
C. Vaughan, III, as printed, not Edward C. Raffensperger, as listed in the Con-
tents.

The Editor and Publisher apologize for these errors.

TRANSACTIONS V STUDIES

of

The College of Physicians of Philadelphia

Volume 37
(Fourth Series)

Number 3
(January 1970)

Health Care for the 1970's 1

By JOSEPH T. ENGLISH, M.D. 2

THE College of Physicians of Phila-
delphia was born in a time and
climate of revolution.
Its first meeting was held on January 2,
1787 — nine months before another group
of men, in this same city, were to sign a
document designed to ". . . form a more
perfect Union, establish Justice, insure
domestic tranquillity, provide for the com-
mon defense, promote the general Welfare,
and secure the Blessings of Liberty. . . ."

Eleven years earlier, also in this same
city, one of the officers present at that first
meeting of the College, Dr. Benjamin Rush,
had been among the signers of still another
document which proclaimed to the world
that the rights to life, liberty, and the pur-
suit of happiness were both self-evident and
inalienable.

And nine years earlier still, in 1767, John
Morgan had proposed the idea of a Phila-
delphia College of Physicians to Thomas
Penn. Thus, the birth of this enduring in-
stitution is interwoven with the events, the
ferment of crisis and change, that produced
the American Republic.

1 James M. Anders Lecture XLVIII, The College
of Physicians of Philadelphia, 5 November 1969.

2 Administrator, Health Services and Mental
Health Administration, Department of Health,
Education and Welfare, 9000 Rockville Pike,
Bethesda, Maryland 20014.

The Pennsylvania Packet and Daily Ad-
vertiser, in its issue of February 1, 1787,
published the constitution of the newly
created College. Its declared purposes were:
". . . to advance the Science of Medicine,
and thereby to lessen Human Misery, by
investigating the diseases and remedies
which are peculiar to our Country, by
observing the effects of different seasons,
climates and situations upon the Human
body, by recording the changes that are
produced in diseases by the progress of
Agriculture, Arts, Population, and Man-
ners, by searching for medicines in our
Woods, Waters, and the bowels of the
Earth, by enlarging our avenues to
knowledge from the discoveries and pub-
lications of foreign Countries; by ap-
pointing stated times for Literary in-
tercourse and communications, and by
cultivating order and uniformity in
the practice of Physick."
Allowing for the impact of time on lan-
guage, that statement of purpose bears re-
examination today, nearly two centuries
later. We are again in a time of ferment, of
crisis and change. Where do we stand to-
day:

In our efforts "to lessen Human misery?"

In our understanding of "the effects of
different . . . situations upon the human
body?"

191

192

JOSEPH T. ENGLISH

In coping with the changes produced by
progress in ". . . Population and Manners?"

In "cultivating order and uniformity in
the practice of Physick?"

We have moved through 18 decades. Dur-
ing the last three of them, the science of
medicine has advanced unbelievably. Yet
human misery still surrounds us. In fact,
the main difference between today's misery
and that of 1787 is that today we have the
capability for alleviating it which the found-
ers of the College did not. We have not yet
found ways of delivering that capability
where the misery is greatest.

In these 18 decades, we have achieved
some order and uniformity in medical
practice, viewed in the narrow context of
what the physician does. We have achieved
neither order nor uniformity if we view
medical practice from the outside, in the
setting of the universe of need. There is
neither order nor uniformity nor equity of
access to medical service. There is neither
order nor uniformity nor efficiency in the
way the health care system works.

In fact, these same purposes which the
founders of The College of Physicians of
Philadelphia perceived in somewhat dif-
ferent form and to which they addressed
their new institution in 1787 are those
which confront us as we enter the 1970's.
They are central to the crisis we face in the
delivery of health care. How shall we apply
the advances of medical science to the less-
ening of human misery with equity, effi-
ciency and dignity?

The existence of a crisis in the delivery
of health care is proclaimed in our daily
newspapers. Our growing population,
which is also growing more sophisticated
every day, knows there is a crisis. People
know about the miracles of modern medi-
cine. They also know, through experience,
of the unmet needs in terms of both quality
and quantity of care available. They
wonder how the same ledger can contain
such contrasting entries.

We in the health professions are becom-

ing more widely aware of the dark side of
the ledger. We know:

That the United States ranks 15th among
the nations of the world in infant mortality;

That we are 22nd in life expectancy for
adult males;

That nearly half the women in this
country giving birth in public hospitals this
year will have had absolutely no prenatal
care;

That 22 per cent of the children born of
these women will be born prematurely;

That 5 per cent of all children born this
year in this country will be born mentally
retarded, and that 75 per cent of those
mentally retarded children will come from
urban and rural poverty areas;

That a poor child born in the United
States in 1969 has twice the risk of dying
before his first birthday as would one of
our children, and four times the risk of
dying before reaching the age of 35.

We also know enough to suspect some
relationships among these facts — between
lack of prenatal care and infant mortality,
prematurity and mental retardation, for
example. The relationships between these
national data and specific local situations
are becoming clearer. In a study of the City
of Chicago in 1963, for instance, there is a
striking correlation between infant mor-
tality and premature birth rates and the in-
come levels of the population.

Meanwhile, other very relevant facts are
being added. In the Kenwood section of
Chicago — a very low income area today —
there were 42 physicians 20 years ago serv-
ing a population of about 25,000. Today,
46,000 people live in Kenwood, served by
two physicians.

Nor is this exclusively a problem of the
urban ghetto. In a county seat town in the
eastern part of the State of Washington
there were, just ten years ago, six physicians
and a good small hospital. Since then two
have died; one has retired; a fourth has
moved to Seattle. When one of the two
remaining doctors decided to follow his

HEALTH CARE FOR THE 1970's

193

colleague to the city, the last one faced the
fact that he could not operate the hospital
alone. The population needing care has
remained relatively stable. The care avail-
able to them has virtually vanished.

This example illustrates another signifi-
cant point. The health care crisis is not
confined to the poor — for this is a relatively
wealthy agricultural area. Certainly the
situation in the ghettos and in the rural
poverty pockets is the most desperate and
cries out the most urgently for solution. But
the crisis is national. It is nation-wide. And
it is felt to some degree by non-poor as well
as poor, by suburbanite as well as central
city-dweller and farmer.

On July 10, 1969, Secretary Robert Finch
of HEW and his newly appointed Assistant
Secretary for Health and Scientific Affairs,
Dr. Roger Egeberg, presented to President
Nixon their assessment of the health care
challenge. The report opened with these
words:

"This Nation is faced with a breakdown
in the delivery of health care unless im-
mediate and concerted action is taken by
government and the private sector."

Those are grave words. They cannot be
taken lightly, coming from men accustomed
to dealing with crisis in its most urgent
forms. The course of health care in the
1970*s will determine whether or not we
avert that breakdown. Will we be able to
take immediate and concerted action, and
will it work?

The lessons of the years just past should
be instructive to us. We have, it seems to
me, acted upon and exploded two myths
in the past 20 years.

The first of these myths was that massive
investment of money and talent in bio-
medical research would result in advances
that would automatically be transmitted
throughout the health care system to the
benefit of all. We made the investment.
The advances came — brilliant advances in
every field of medical science and technol-
ogy. But the automatic transmission

throughout the system did not occur. In-
stead, the gap between the best in medic ine
— which rose rapidly — and the medicine
available to great numbers of our people — ■
which did not — became wider.

The second myth was that the problem
of access to the best in health care was
strictly a financial problem. All that stood
between some 30 to 45 million people and
the mainstream of American medicine was
lack of money. If they were given a money
ticket into the system, we assumed, they
would then automatically be able to par-
take of the highest medical excellence.

This mythology was the subject of in-
tense debate. But the debate centered on
how to issue the money ticket, and whether
it should come from governmental or pri-
vate sources. Enactment of the Social Secu-
rity Amendments of 1965, which created
Medicare and Medicaid, was the outcome
of this economic and ideological dialogue.

But the validity of the myth itself was
scarcely debated at all. Today 76 per cent
of the greatly increased total federal invest-
ment in health is devoted to the financing
of health care — to the issuing of money
tickets. And today we are learning pain-
fully that again no automatic, universal
access to the mainstream of medicine is
occurring. For millions the mainstream still
does not flow. There is no one to honor
properly the tickets they possess.

The result has been a greatly heightened
demand — effective demand in the economic
sense — for high quality health care. This
demand has placed enormous stress on the
capacity of the American health enterprise.

Physicians face greatly increased patient
loads — sometimes double or triple the load
they were bearing before. Inevitably this
strains each physician's capacity to give
every patient the highest quality care. It
drives him to increase his charges — in part,
at least, to protect his own coronary vessels
by buffering the demand. The sheer weight
of numbers of patients seeking his attention
forces him to put those who are seriously

194

JOSEPH T. ENGLISH

ill into hospitals — many of whom might
have been cared for outside the hospital in
other circumstances. This, in turn, strains
the already overtaxed hospital resource.

Thus, we risk dilution of the quality of
care. We experience skyrocketing inflation
in medical prices. We find increasing in-
equities and indignities in the human rela-
tionships involved in health service. All of
these happenings — which are part of the
potential "breakdown" to which the Secre-
tary and Dr. Egeberg referred — are the
products of an unprepared system laboring
under overwhelming quantitative demand.

It should not be inferred that the Na-
tion's investment in biomedical research
and its more recent investment in the
financing of care were not important and
necessary. Research has led and will con-
tinue to lead to heightened medical capa-
bility without which the whole medical
enterprise would wither and die. Medicare
and Medicaid have knocked down the finan-
cial obstacle to medical care for millions of
people who desperately need it.

Rather, the point is that neither of these
two investments has solved the basic prob-
lem of getting good health care to all who
need it. Standing between them and that
goal is the capacity of the health care system
to deliver.

Later on in their report to the President,
Mr. Finch and Dr. Egeberg wrote:

"Our task now as a Nation is to acknowl-
edge the extreme urgency of the situation,
to take certain steps to arrest the inflation
that is paralyzing us, and to put in motion
initiatives that ultimately will reshape the
system. This task is obviously not one for
government alone, although government
has a major role to play. Much of the
burden must be taken up by the private sec-
tor since it has the primary responsibility
for the delivery of health care."

The Secretary and Assistant Secretary
then listed a number of specific responses to
this crisis. Among these initiatives were a
number of actions designed to build the

capacity of our national health resources,
so that they can respond to the scale of the
challenge. These responses recognize the
central fact that governmental action in the
health care field must, because of the par-
ticularly local and personal character of
medical care, have its impact in the com-
munity. For it is there that doctors and
hospitals face, every day, the demands of
serving more people better than ever before.

There is a great feeling in this country,
supported by many studies, that our greatest
need is to develop primary family health
care. Primary care is the point of entry into
the system. It is the point where the great
quantitative need can and should be met.
Yet what is the nature of primary care in
this country today?

For the 46,000 people who live in the
Kenwood section of Chicago, with two
physicians, primary care is Cook County
Hospital which sees one million patients
per year. For literally millions of people,
primary care is a long bus ride, two hours
on a hard bench, impersonal treatment by
the numbers, perhaps at the end of it a
referral to another time and place involving
another bus and another bench. Different
but also acute problems confront the rural
and suburban American in pursuit of pri-
mary care.

This is not the face of American medicine
that we like to present to the world. It is
not the face we tend to talk about when we
assemble in our medical forums to discuss
the present and future. In fact, this is an
important part of the problem. No medical
institutions exist to whom we can address
the big questions like "Whose responsibility
is primary care in the 1970's?"

The physician, through the institutions
and organizations he has created, has always
accepted responsibility for what he does. He
bears with pride the full weight of respon-
sibility for his patients, and this is a respon-
sibility of life and death in the most literal
sense. But neither he nor his professional
organizations nor any other institution in

HEALTH CARE FOR THE 1970's

1') i

win so(ici\ has accepted tespoiisibilily tor
what the physician docs not do — lor the
"real numbers ol people needing health
care who arc no one's patients.

What we urgently need today is a revolu-
tion in the institutions ol medical caie that
will cieate new loci ol responsibility. Heir
in this city, which cut its teeth on revolu-
tion, ihis should be not a threat but a
challenge.

Fhe shape and substance ol these new in-
stitutions is not yet clear. But it is very
clear that they must evolve out ol the
public -pi i\ ate partnership that is now
being built. Neithei private medicine alone
nor government alone can do the job.

Hopeful signs aie beginning to emerge.
The revolution is already underway. Let
me cite a few examples.

When the Federal government estab-
lished the Headstall program a lew years
ago, it was seeking to meet head-on the
problems of poverty's child, Fo meet the
critical health needs of the Headstart chil-
dren, one of the great institutions of private
medicine, the American Academy of Pedi-
atrics, stepped forward to assume respon-
sibility. As of the first of this month, 697
pediatricians are currently at work on
I leadstai i projee ts, and anothei 272 ai e en
rolled and reach to be assigned as soon as
projects get underway. This is private-
public collaborative effort at its best.

When government confronted the prob-
lems of the Watts community in Los
Angeles, anothei private institution — the
Medical School of the University of
Southern California, then under the direc-
tion of Dr. Egeberg — accepted major re-
sponsibility for the medical aspects of that
task in cooperation with the Neighborhood
Health Centers program of the Office of
Economic Opportunity. Toda\ 10 OEO
health projects are actually administered by
medical schools, another 10 by teaching or
community hospitals, two by medical
societies and 3 by group practice organiza-
tions. In all, nearly half the medical schools

of the country and some l. r > medic al mk ict its
are involved in the operation ol Neighbor-
hood Health Centei projects.

In Seattle, the Washington State- Medical
Society and the Medical School of the Uni-
versity ol Washington are co-sponsoring
with the Fedei a] govei nmeni a projeel
designed to take advantage ol a great un-
tapped source ol medical expertise — return-
ing medical corpsincn ol the aimed loices.
Fifteen men with up to 1900 hours of
formal medical training are now working
with private physician-preceptors, using
skills gained in a inilit.ny setting. They
are caded Medex from the French phrase
medicin-extension — and the) ma\ be the
vanguard ol many mole. I wo ol these men,
incidentally, are now working in that com-
munit) which had lost almost all its physi-
cians. 1 he lact that the) are there has
enabled the- hospital to stay open.

In a West Oakland slum area, across the
bay from San Francisco, 50 physicians and
dentists now serve a community that had
only live health professionals a lew vcars
ago. They are there because the West Oak-
land Health Center is there. The West Oak-
land Health Center is there because cont-
inuum residents — all black, none wealthy,
only a lew high school graduates — studied
their health needs and found the resources
and the leverage to meet them.

More examples could be cited — not
enough, but an indication that new health
institutions are evolving, cut tej the measure
ol the health challenge of the '70s. Each of
these examples illustrates a dilfcrent kind ol
public -private partnership.

By far the greatest share of the increased
Federal investment in health in the past
lew years has been on the financing side ol
the equation. Medicare and Medicaid to-
gether account for more than three-fourths
of the $14 billion Federal input in the $53
billion health industrv. Bv contrast the
governmental investment in building the
capacity of the system is verv small.

Yet several programs, mostly of very

I'M,

JOSEPH T. ENGLISH

recent origin, are now underway with the
purpose of strengthening capacity by im-
proving the w;i\s in which health care is
organized and delivered in the community.
Most, though by no means all, of these are
now pulled together in the Health Services
and Mental Health Adminisli ation, or
I ISM HA as we call it. We believe this big
new agency has a vital role to play in meet-
ing the challenges of health care in the
1970s.

The aim ol HSMHA is to strengthen each
component involved in the delivery of care.
We are involved in partnerships with every
element of the purveyor system — the physi-
cians, the hospitals and other community
institutions and agencies, state and regional
authorities, voluntary groups. We are also
in partnership with the consumers of health
care who have an important role to play
in assuring that they are well served.

Within HSMHA, several specific pro-
grams provide us with levers for helping to
raise the capacity of the national health
resource at the community level, where
medical care happens.

The National Center for Health Services
Rese u (h and Development, formally estab-
lished on July 1 of last year, stimulates
and supports experimentation with new
methods of delivering health care. It seeks
to apply sc ientifu methodology in the social
and behavioral sciences to problems of
medical tare organization and delivery in
the community setting. Among its highest
priorities are devising new approaches to
the delivery of medical care for the poor
and testing methods which show promise
of controlling and reducing health care
costs. The Medex project in Seattle is one
example of an innovative approach spon-
sored by NCHSR 8c D.

Project grants under the Partnership for
Health are encouraging new ways of deliver-
ing care. They support innovative efforts of
a variety of health institutions and agencies.
Many of these projects are also reaching
into neighborhoods and districts where care

has been least accessible in the past, with
emphasis on primary ambulatory care. The
West Oakland Center is one of a growing
number of such projects.

The Regional Medical Programs consti-
tute a powerful resource upon which the
community may draw for resolution ol
health problems. They pull together into an
eflc< live I uni tioning alliance the lull medi-
cal strength of the region, to assure that the
best in care can in fact be delivered where it
is needed.

The Maternal and Child Health pro-
grams formerly administered by the Chil-
dren's Bureau of HEW have just been
transferred to HSMHA this past month.
I hey represent M'Im million of Federal
suppoit lor project and lot inula gi ants to
States and communities. Much of this sup-
port underwrites primary care in the family
and neighborhood setting, including family
planning services as an integral part of
health care. The new organizational place-
ment of these programs gives us an oppor-
tunity to strengthen greatly the total impact
of our efforts.

At a somewhat more sophisticated level
of care, we have a strong lever in the Com-
munity Mental Health Centers Program.
The intent here is to deliver mental health
services as a part of the total health care
package within a community.

The Hill-Burton facilities construction
program has long been a primary tool for
enhancing the capacity of the total system.
As priorities of need are changing, the
emphasis of this effort is changing toward
helping the hospital make its maximum
contribution to the total spectrum of com-
munity health care.

As we view them, these and the other
Federal health service programs should con-
stitute resources on which the community,
and its private medical institutions, can
draw. The place where they need to fit to-
gether is in the community. Our task as
administrators is to help this synthesis to
happen.

HEAL! 11 ( \kl FOR I HE 1970's

197

Our support of areawide planning agen-
( it's undei the Pai tncrship lot I [callh A. i is
one mechanism designed to help achieve
this synthesis at the community level. The
role of these agencies that we see emerging
is one ol community trusteeship. These
agencies should bring together the con-
sumer and the purveyor of health services
to oversee the distribution and use of re-
sources, identify the unmet needs and set
realistic priorities. They represent not an
operating agency but rather a focal point
Eoi community responsibility in health.

This batter) ol Federal health programs,
plus others that could be listed both within
and outside HSMHA, does not constitute a
solution to the problem. Rather, it con-
stitutes an invitation. If these programs are
to work at all, they must be met halfway —
and more than halfway — by the private in-
stitutions ol health care. You, here in The
College of Physicians of Philadelphia, and
your colleagues and counterparts across the
Nation, are the ones who ultimately must
resolve the health care crisis.

The crisis is very real. The people of this

country knoM what good health care means,
.ind the} want il very much. I he) a i e noi
satisfied with what they are getting, with
the price they are paying for it. You can
hear the voices of discontent in the poorest

ghetto .ind in the si sophisticated unk-

tail party. 1 hese voices will not be quiet
until the need the\ express is fulfilled.

Looking li.nk across 200 years, I would
sa\ that the Philadelphia College of Physi-
cians is no stranger to crisis. It was born in
crisis and its founders were involved in rev-
olution. The purposes to which it was
dedicated are alive and meaninglul toda\
to advanc e the science of medicine, to lessen
human misery, to bring order and uni-
formity to health care.

All thai has changed is the context — of
quani itative demand for medical excellence
undreamed of two centuries ago. The Col-
lege of Physicians of Philadelphia, on the
threshold of the 1970's, faces the revolu-
tionary challenge of helping to make that
medical excellence universally available
with equity, with efficiency, and with
human dignity.

125th Anniversary Salute: The Philadelphia
Birthplace of the American Psychiatric

Association 1

By ROBERT ERWIN JONES, M.D. 2

ON the evening of October 15, 1844,
iliiiiccn 1 ihysicians assembled in the
parloi (Figure \) of a red brick
( .coi g i.in l.umliouse (Figure 2) on the
gioiinds ol the Institute of the Pennsylvania
Hospital, the home of the superintendent,
l)i . I homas S. Kil kb] ide.

This modest setting was the birthplace of
the Inst national medical organization in
America. The men were superintendents of
thirteen ol the twenty mental hospitals
which existed in the country at that time,
and they called their group the Association
ol Medical Superintendents of American

— r-

1 SSJ

Fig. 1. First meeting place of the founders
1880 oil painting by Liberty Tadd shows the (
Kirkbride at Haverford Avenue and 4tth Stieci

1 This paper appeared in part in Psychiatric
News, official newspaper of the American Psychiatric
Association, Vol. IV, No. 10, October 1969, pp. 12-
13.

2 Associate Medical Director. The Institute of the
Pennsylvania Hospital, 111 North 49th Street,
Philadelphia, Pennsylvania 19139.

of the American Psychiatric Association. This
lining room-study in the home of Dr. Thomas
in Philadelphia.

Institutions for the Insane, now known as
the American Psychiatric Association. Its
founding preceded the organization of the
American Medical Association by three
years.

Built in 1796, the house was previously

198

21 ii i

ROBERT I RWIN [ONES

'9

■jfi* /A* r / /■*»*{. ///v;vt^uy./..„, i .// J

j.;..>:.. y,-, £* ''■•»

(■ >// J, 7r& o ///U <4 > as i -•• m >/ju

-At/tor, <■ *.<■.€/. A.

/cui. V Juiln KtjktvJrArtL SkJa*i MiH^J CI.

C' M ... /5< s A.,/,./u

..'■}>!<,{:,.'„ Jt. €.Ml& <Gu—A \ vAy 4*»w

,'.1 i, I,* . /

j jfc-

FlG. 4. Signatures of the 13 founders in the
"Visitors Book" at Pennsylvania Hospital. Wives
also attended the lirst convention.

the residence ol Paul Busti, a successful
Italian immigrant merchant and representa-
tive ol a Dutch trading company. A promi-
nent avenue in Buffalo, New York, still
hears his name.

This landmark in the histoiy ol Ameri-
can medicine has been completely restored
(Figure 3) and now serves as a recreation
center lot a neighborhood playground. The
original furniture and objets d'arl from the
room are preserved in the historical museum
at Pennsylvania Hospital. Many of the
books have been donated to the APA li-
brary in Washington, D.C.

The hospital "Visitors Book" contains the
onh known record (Figure 4) of all 13 signa-
tures of the APA founders. Dr. Kirkbride's
correspondence contains letters from all
Eounders except Dr. Samuel White, the first
vice-president and oldest of the group, who
died a few months after its founding.

The founders' letters to and from Dr.
Kirkbride, first APA secretary and later

Fig. 5. The Jones Hotel, scene of the officia
beginning of the American Psychiatric Association,
no longer stands on Chestnut Street above 6th, one
block from Independence Hall.

Fig. 6. Dr. Thomas S. Kirkbride, first secretary
of the APA and host of the first convention.

\MI Kit \\ I'sN ( I II A I RIC Assoc I \ I |( )\

H 1 1

president, rceoid ih.it the ide;i lor the orga-
nization developed in the spring of 1814
w hen Dr. Samuel Woodward, siipei inlend-
ent of the Stale Lunatic Asylum at Wor-
cester, Massachusetts, journeyed south to
\ isil Dr. Francis r. Stt ibling ol the West ei n
Lunatic Asylum in Staunton, Virginia. Dr.
Kirkbride wrote to Dr. Stribling (June I.").
1844):

" \s i espec ts a i onvciil ion ol I he Medic al
Superintendents ol Insane Hospitals, I
agree with von that much benefit might
result from such a meeting, particularly as
respects the statistics of such institutions.
I here are some difficulties in the way, how-
ever, and preparatory to a meeting it ap-
pears to me that all should be aware of the
matters likely to be discussed and have some
idea of what plans are likely to be proposed
for general adoption. To be efficient, the
action of such a convention should as far as
possible embrace all the asylums of char-
acter in the country. Should Philadelphia
be selected as the place for meeting, I should
be very glad to do everything in my power
to make all who attend perfectly at home
and to see to any preparatory arrangements
that may be required."

On August 22 he wrote:

"1 . . . shall take great pleasure in making
arrangements you suggest, relative to the
meeting of Physicians to Hospitals for the
Insane to be held in Philadelphia in Octo-
ber next. I had already concluded to make
an arrangement with Mr. Jones for any ac-
commodations we might desire, and no
better place for first getting together could
he designated."

At Dr. Kirkbride's invitation, the super-
intendents gathered for dinner at the Kirk-
bride residence. There they formulated
some preliminary plans, which were con-
firmed the following day when the group
met at ten o'clock in the morning at the

[ones Hotel (Figure .">), whit h stood on
Chesinui St i eel aho\e lit 1 1 . one hlo(k liom

Independent e Hall.

The founders quickly developed a high
rcgaid lot one anolhei and an cspirit <\e
corps among themselves in caring loi the
"(lass ol unfortunates," as l)i. Stiihling
called the insane. Isa.u Ray referred to the
group as "In ei hi en"; [ohn S. Butler nick-
named them the "Old Originals." They
joked aboul themselves as "mad doctors"
or "insane doctors." None, of course, called
himsell a ps\c hiati ist. although Plim Faile
came close bv calling them "rich psy-
c hiatci s."

On the evening of October 20, 1844, the
Association adjourned to meet in May 1846,
in Washington. D.C. The members felt
that theii meeting had been a success. Dr.
Samuel Woodward, who was elected the
li i si i n esident, wrote to Dr. Kirkbride:

" The time spent in Philadelphia was one
of the most profitable and agreeable seasons
that I have ever enjoyed. I trust much good
will come from the convention and hope
the ardour manifested at the meeting will
not be suffered to cool so as to prevent full
and able reports on all subjects assigned to
committees."

And years later, in 1854, Dr. Ray wrote
to Dr. Kirkbride:

"If our yearly conventions had accom-
plished nothing more than to make us
acquainted with one another, and with
other institutions beside our own, creating
Icelings ol personal i egai d and mutual sym
pathy, I should think they had not been in
vain."

Dr. Kirkbride (1809-1883) (Figure 6) was
a Fellow of The College of Physicians of
Philadelphia. His portrait by Howard R.
Butler hangs in Thomson Hall of the Col-
lege.

Memoir of Sir Henry Hallett Dale
1875 1968*

By GEORGE B. KOKI.I.K, I'll. I)., M.D.

THE death (.1 Sh Henrj Hallet) Dale
al the age <>l 93 on |ul\ 23, I9(i8, lias
been n ul\ < hai a< tei 1 /< ■« 1 .is 1 he end
<>l an era (I). Willi the exponential in-
crease in the numbers of investigatoi s in
all fields ol sc ieiu e dm i'iil; the piescnt cen-
tury, only a very lew ol theii names can
be expected to achieve a clegiee ol per-
manency that will insure llieii being
quoted beyond the Immediate Euture, ei-
ther in histories of science or in the bib-
liogiaphics of contemporary research and
review publications. Sit Henr) Dale will
smeh be one of these. His extensive series
of brilliant and meticulous investiga-
tions in several areas of pharmacology and
physiology, along with his carefully drawn
conceptional conclusions, established him
as one ol the world's foremost figures in
these disciplines. Dale's research achieve-
ments were recognized In main awards
and honors, including the Nobel Prize
which he received along with Otto Loewi
in 1936 for their major, independent con-
tributions towards establishing the theory
of neurohumoui.il transmission. Dale
served, and consequently influenced in a
still broader sense, medicine and science in
general in his successive capacities of
President of the Royal Society, of the Brit-
ish Association, of the Royal Society of
Medicine, and of the British Council, as
well as that of Chairman of the Scientific
Advisory Committee to the British War
Cabinet during World War II. As Chair-
man of a Conference of the Health Organi-
zation of the League of Nations in 1925,
he was primarily responsible for the adop-

* Prepared at Pahlavi University, Shiraz, Iran,
at the request of the Council of The College of
Physicians of Philadelphia.

tion ol international standards of drugs
that required biological standardization.
In addition to his activities in these
official posts, Sir Henry was throughout
his life regarded by the medical community
as a source without peei for sound judge-
ment, careful criticism, and enthusiastic
interest, both at scientific meetings and
in the private interviews for which he
made himself available freely until the
time of his final illness.

It would be impossible in a short space
to review Dale's direct scientific contribu-
tions, their broad significance, and their
major impact on subsequent research. This
has been done admirably in a memoir
prepared by his longtime friend and scien-
tific collaborator, William Feldberg (1),
and in a delightful anecdotal account writ-
ten by Dale himself, half-a-dozen years
before his death (2). Accordingly, only the
most important highlights of his scientific
career will be mentioned here.

Following his graduation from Cam-
bridge in 1898, Henry Dale remained two
additional years as a research student in
physiology under J. N. Langley. He then
completed his clinical studies for his med-
ical degree at St. Bartholomew's Hospital,
London; remarkably for a pharmacologist
of that time, this was his last formal aca-
demic affiliation. Having decided upon a
career in research, Dale spent a brief period
in Paul Ehrlich's Institute at Frankfurt.
He then accepted an appointment to un-
dertake pharmacological investigations at
the then recently established Physiological
Research Laboratories of Burroughs Well-
come and Company, where he remained as
an active investigator for ten years, and
subsequently served as Chairman of the

202

Ml MOIR 01 Ml< III MO ll \l I I I I DALE

203

Wellcome rrust, I Ik- remainder ol Dale's
careei .is a direcl participanl in research
was spenl al the National Insiituu- for
Medical Research, when- Ik- was Director
Erom 1928 until lus retirement in 1942.

As I). ik- himsell often pointed out, sev-
eral o! his major discoveries originated
Erom an investigation ol the pharmacolog-
ical pro] ici l ics ol the crude di ug, cigol,
which he undertook at the suggestion of
Sii I Itm \ Wellcome after joining the
company's laboratoiv. These included the
lusi dcinonsl i at iou ol adicnergii blockade;
the isolation, phai mac ological characteii-
zation, and exj>loi at ion ol the physiolog-
ical oi pathologic nl significance' of tyra-
inine, histamine, and acetylcholine; and
the discovery of the oxytocic action of pos-
terior pituitary extract. From related stud-
ies. Dale introduced the concept of lixed,
as opposed to calculating, antibodies as
the basis ol anaphylaxis and hypersensi-
tivity.

Dale's major research achievements were
in the conception, establishment, and ex-
tension of the theory of the chemical trans-
mission of nerve impulses, or neurohu-
moural transmission. Earl\ suggestions of
i his were made by Du Bois-Rcymond and
Lewandowsk) in the preceding ccniui\.
and l>\ T. R. Elliott and J. N. Langley
shortly before Dale's pi cceptecship in the
latter's laboratory. While comparing t he-
actions of a large number of synthetic
epinephrine like compounds in collabora-
tion with G. Barger at the Wellcome lab-
oratory, Dale like his predecessors was im-
pressed with the resemblance between the
actions of main of these drugs and those
of the sympathetic nervous system; how-
ever, with characteristic caution he
pointed out that epinephrine did not
mimic such nervous influences as closely
as did norepinephrine, a compound which
then was not known to occur in the body.
(Oyer thhty years later, von Eider showed
that the actual sympathetic transmitter is
in fact norepinephrine). Shortly after-

w.uds, during his analysis ol the actions
ol acetylcholine, Dale noted the close iden-
tity betwee n iis ac tions and i hose of
parasympathetic impulses. During these
studies. Dale coined the teiins "sympatho-
mimetic" and "parasympathomimetic,"
which like main otheis which he- intro-
duced are standaid in the current medical
literature. Endowing Olio Eoewi's dem-
onstration that vagal impulses to the frog's
he.n l are transmitted by a chemical agent,
and his identification of the transmitter as
acetylcholine shortly afterward, the sub-
sequent confirmation and extension of this
principle were due largely to the work of
Dale and his many col tabulators. Out-
standing among ihis gioup were (.. E.
Brown. J. EI. Burn, J. Gaddum, W. Kc-ld-
berg, and M. Vogt. Togcthei. ihe\ showed
that acetylcholine is ihe iiansnhttei also
lor mammalian postganglionic parasym-
pathetic fibres and a few sympathetic fibres,
preganglionic fibres of the entire auto-
nomic nervous system, and the motor
nerves of skeletal musc le; in addition, ihe\
obtained suggestive evidence of choliner-
gic transmission at certain sites in the cen-
tral nervous system, which has been amply
confirmed in recent years.

The sequential announcement of these
findings during the 1930's must have gen-
erated considerable excitement, for unlike
now, the concept of neurohumoural trans-
mission was at that time by no means
generally accepted. Fur example, w hen Dale
presented at one meeting the evidence that
acetylcholine is the transmitter of sym-
pathetic impulses tu the sweat glands, the
physiological significance of his findings
was challenged b\ one young listemi
(who subsequently also received a Nobel
Prize). Dale replied that the same mis-
givings had occurred to him, but that he
had reassured himself as follows: A few
days previously, he had played several sets
of tennis, then adjourned immediately
to the laboratoiv, where he had extracted
his socks with saline solution and tested

2D1

GEORGE B. KOELLE

the extract for acetylcholine-like activity on
the leech-muscle preparation; the result
had been distinctly positive.

A total list of Sir Henry Dale's collab-
orators during his active investigative years
would include many of the world's out-
standing pharmacologists and physiologists
of two generations. Among these were
two of Philadelphia's most distinguished
medical scientists, Alfred Newton Rich-
ards and Julius H. Comroe, Jr. It was a
historic occasion in September, 1953, when
Dale, Loewi, most of the aforementioned
investigators, and a host of others met in
Philadelphia for a two-day Symposium on
Neurohumoural Transmission (3). This
was probably the last formal assembly of
these two giants of research, their disciples,
and their scientific proponents and ad-
versaries. The years that have followed
have seen tremendous advances in our

knowledge of the function of the nervous
system at all levels, from the behavioral
to the molecul.n. Jn pace with this prog-
ress has been the development of a large
number of new and more effective drugs
for the treatment of nervous and mental
disorders, the neurogenic aspects of hyper-
tension, and a variety of other illnesses.
The foundation of much of this work
can be traced back directly to the researches
of Dale and his associates. The College of
Physicians of Philadephia is indeed hon-
ored to have had Sir Henry Hallett Dale
among its Honorary Fellows.

REFERENCES

1. Feldkerc, W.: Henry Hallett Dale, 1875-1968.

Brit. J. Pharmacol. 35: 1-9, 1969.

2. Dale, H. H.: Pharmacology during the Past Sixty

Years. Ann. Rev. Pharmacol. 3: 1-8, 1963.

3. Koelle, G. B. and Krayer, O., Ed.: Symposium

on Neurohumoural Transmission. Pharmacol.
Rev. 6: 1-131, 1954.

The Custodianship Cabinet of The College

of Physicians

The recent redecoration of the Hutchinson Room, of] the main foyer of the
College Hall — instigated by President Francis C. Wood, supervised by Mrs.
Wood, and generously contributed as a gift of Dr. and Mrs. Wood to The
College of Physicians — required the moving of the Custodianship Cabinet,
which contains mementos of five of the world's greatest healers. A pamphlet,
describing the mementos, was found beneath the glass case.

The author of the pamphlet could not be identified. However, a search by
W. B. McDaniel, 2d, Curator of Library Historical Collections, revealed that
the booklet is referred to in an account of a "Special Meeting in Honor of
Madame Curie" at the College on May 23, 1921. The opening overture is an
"Address of Robert Abbe, M.D., New York." Mrs. L. M. Holloway, Associate
Curator and Cataloguer of Historical Materials, then discovered that there is a
copy of the pamphlet among Dr. Abbe's collected reprints, a fact which indi-
cates that he is the probable author. Miss Marie deBenncville provided bio-
graphical information about Dr. Abbe.

Because the pamphlet has been out of circulation for many years and because
of its rarity, it is reprinted in this issue in a form similar to the original. The
address of Dr. Abbe (Figure 1), collector of the mementos, is also reprinted as a
preamble to the pamphlet itself.

The Custodianship Cabinet had its beginning in 1920 when Dr. Abbe pre-
sented the College with the gold watch of Benjamin Rush. The next year he
donated $5000 with ivhich to maintain or increase the cabinet of mementos of
historic persons who greatly added to the advancement of science.

Dr. Abbe was born in New York City in 1851. In 1922, he became interested
in the many stones that he found on a street in Bar Harbor, Maine. This interest
resulted in the founding of the Lafayette National Park Museum of the Stone
Age Period in Mt. Desert Island, dedicated in 1928.

His chosen profession, however, was medicine, and his practice was based
upon the soundest principles. One biographer wrote: "His alert mind and
pioneer spirit led him far beyond the routine of a surgeon's practice." He
worked with the hope that much that he was doing in surgery might be better
and painlessly done through future discoveries. He became a missionary for
the discovery of radium by Professor and Madame Curie, but he met with criti-
cism for his prompt use of the element.

Additional mementos have been added to the cabinet since 1921, and a
pamphlet describing them will be prepared.

The conditions of the custodianship require that, if a custodian fails to name
his successor, one shall by chosen by the Council of The College of Physicians.
The most recent custodian (1928-39), Dr. William J. Mayo, died without nam-
ing a successor. The task of choosing a new custodian, after a 30-year lapse, now
aiuaits Council.

The Editor

205

206

ROBERT ABBE

SPECIAL MEETING IN HONOR OF MADAME CURIE*
ADDRESS OF ROBERT ABBF, M.D.
New York

You will find ;m illust i alcd booklet in
each seat of this hall describing the memen-
tos of the five great names of om profession
and of science, which are the milestones of
scientific progress in the healing art dining
the past century or more. These mementos
are tonight exhibited for the first time in a
(.isc in which thev will permanently remain
in you] keeping.

Fig. I. Robert Abbe, M.D., originator of the Cus-
todianship Cabinet.

Your reading of this booklet now or at
your leisure will save the time necessary for
the telling and enable me to occupy the few
moments before Mme. Curie's coming to-
night to explain more fully the object of
her presence here and of her visit to our
country.

Those of us who arranged her itinerary
in this short six weeks between her leaving

* Read May 23, 1921.

Paris and returning to it have faced an
enormous demand for her presence at uni-
versities, societies and cities all over our
country. Knowing her delicate health, and
the need of conserving her strength, we have
chosen such visits and duties as would satisfy
her wishes and the universal desire of in-
siii in ions of learning to see her, and yield
the greatest benefit to science and popular
education without fatiguing her, and yet
stimulate her life, if possible, to complete
i he u oik lei I ul work ahead ol her.

She comes to us after many years of
fatiguing labor. The great war took toll of
the University of Paris from the first gun
fire. Most of the students and the great
corps of professors and teachers abandoned
the class-room for the battlefield. She was
among the first to abandon her laboratory,
and until the day of the Armistice was at
iIk hont witli her daughter in X-ray work.

When she returned, all was desolate. It
was as if life were either to stop or to begin
over again.

By almost an act of genius the initiative
of an American, Mrs. William B. Meloney,
accidentally a visitor to Paris on another
mission, touched a key that evoked an ap-
pealing note of sympathy in the hearts of
the women of our country. An extraordi-
narily spontaneous response called out
working committees of women all over our
land. By admirable organization one of the
largest purely woman's movements has
excited a sympathetic feeling for the tri-
umph of pure science — as illustrated in
Mme. Curie — and also by innumerable
small contributions from women created a
fund to present her with the accessories for
equipping her disorganized laboratory.

She has confided the fact that one of her
desires has been to come here tonight and
personally present and dedicate the historic
scientific instrument which you see before

SPECIAl MEETING IN HONOR Ol \l \ l > \ \l I CURIl

207

you to such educative purpose as its pres-
ence may evoke.

When I liualh brought ii vilely to my
office .1 few days ago — after many vicissi-
tudes ami unpac ked it tenderly, my assist-
ant was touched by its impressive meaning
and said. "Don't you think it will be lonch
over here?"

I said. "Yes, perhaps, until Mine. Curie
COines and places bet hand affectionately
on it and commends it to our care."

That, my friends, she will do in a lew
moments.

Her reception in this country will be a
just tribute to one ol the world's most dis-
tinguished woman scientists; but nothing,
I judge, can ecpial the- momentous and
thrilling ovation given to her a Eortnight
ago in Paris on the eve of her departure.

The scene was the great Opera House.

The stage was set by Guitry, the Belasco
ol the French Theater. The house was
packed with a distinguished audience.

Flags, decorations and music were elabo-
rate. The curtain rose on a stage filled with
officers of state, professors of the univer-
sity — in robes — and in the center the
modest, shrinking, woman savant. Splendid
addresses were given, laudatory and impres-
sively true.

Then the curtain fell, only to rise again on
a stage cleared of everything but a small
table behind which Sara Bernhardt, the
greatest living tragedienne, rose to deliver
a brilliant eulogy written by the master of
French dramatic writing, Rostand. The ef-
fect was thrilling, but thunders of applause
and calls for Mute. Curie failed to bring her
from behind the scenes where she had been
bashfully listening to Mme. Bernhardt. I
have been told by a lady who witnessed the
scene that there was no climax, but a succes-
sion of tributes, one after the other, fol-
lowed by an elaborate "movie" of Mme.
Curie's life espe< iall) prepared by actors on
the scene of her early home and laboratory
work with her lather, professor in the Uni-
versity of Warsaw, where she was his de-

voted assistant until she came to Paris at
twenty years of age.

The scenes (hen depicted French univei
sit) work in laboratory and mine, with de-
tailed views ol the \ ei ilable w oi kshop and
scenes of her triumph in the epoch-making
discovery of radium.

From such an emotional farewell she
made het lust crossing ol the ocean, and,
yesterday, was the centet ol interest at the
most momentous sc ientilu event e\ei given
at the White House, when President Hard-
ing presented to hei the gilt from the
women ol our countiy, a gram of radium.
The President made one of the most beauti-
ful addresses I have ever heard, full of
charm and dignity. Mine. Curie responded
most happily. Before her was the fine
mahogany box containing the precious
mineral which she had discovered, confined
in an interior case of lead weighing a hun-
ched pounds. The little gold key to this box
was presented to her by the President,
which she afterward wore around her neck
on a tri-color ribbon.

From the fatigue of that and other cere-
monies she comes to us tonight with par-
ticular pleasure to dedicate the memento
which will repose in your cabinet. You will
see in her a woman of rare charm, but t he-
antithesis of all that savors of pompous-
ness. She has the tenderest heart in her frail
body, but the keenest sense for all scientific
conversation, with unalfected disdain ol
small talk.

I desire to say a few words regarding the
care of mementos you see on the platform
and the custodianship ol them, worthy, I
hope, ol your perpetuation.

More than ten years ago, as you know,
there was presented to me the beautiful
gold watch of Dr. Benjamin Rush, one of
your society's founders and a hero of Rev-
oluntionarx days. It was made the subject
of a custodianship to be held as an honor,
by successive members of our profession
who represented the same high qualities of
mind and lifework as he did. The first

20H

ROBERT ABBE

c 1 1 si o< 1 i a 1 1 was I)i. Weir M i I c lull. He those
Dr. Simon Flexner as his ideal and successor.
Di Flexner, afte] three years, passed it on
to Dr. William H. Welch, who accepted the
honor and is its present custodian, to the
delight of everyone, saying: "Why! It's like
the gold-headed cane."

I saw the gold-headed cane in the College
of Physicians' cabinet in London last sum-
mer, and with ii were five other treasures:
First, a pair of scissors belonging to Jcnner
and a cow's horn from one of the historic
animals used in vaccination; second, a small
wooden stethoscope used by Laennec; third,
a short ebony pointer used by Harvey in his
lectures on the blood; fourth, a small silver
platter given in 1661 by the Fellows of the
College, but stolen in 1666 at the looting
during the great fire of London. It was lost
for 250 years and was recovered at a collec-
tor's sale of old silver a few years ago.

1 u as inspired l>\ I Ins sin. ill l;) oup and l>\
lis elle< i upon me lo think I might attpihe
some things worthy to add to our custodian-
ship. My hope was of Lister, Pasteur and
Curie, but from the first inquiry I was given
d i si i mi agement.

Pushing my endeavors during my short
stay in London and Paris, I was at last re-
warded by three remarkable gifts and veri-
table treasures, of each great name, and
these I present tonight:

A box of surgical instruments used by
Lord Lister.

A large model of a tartrate crystal used by
Pasteur.

A wonderful historic instrument made by
Pierre Curie, and used by him and Mme.
Curie in her immortal discovery of radium.

These memorable souvenirs probably
cannot be duplicated anywhere outside of
the Lister, Pasteur and Curie Museums.
They were secured through the assistance
of Dr. Keen and Dr. Gibson, and by the
gifts of Sir Rickman J. Godlee (Mr. Lister's
nephew), of Calmette and Roux (Pasteur's
assistants and successors), and of Mme.
Curie herself.

In the possession of this institution there
has been an inkstand of Jenner, which was
given by Dr. Weir Mitchell, and has been
permitted to repose in this cabinet as one
of the memorable souvenirs.

With these five in the cabinet are por-
traits of each distinguished scientist and a
beautifully bound volume of historic data,
biographic notes and autograph letters of
each.

In addition there are the cutodianship
conditions and portraits of each successive
< ustodian, with his lettei ol nomination
and acceptance.

T hese, in the coming years, will con-
si itute a memorable collection of our own
illustrious scientific, educational and hu-
manitarian fellow-men whose deeds and
lives will be worth emulation.

When, in a few minutes, Mme. Curie
arrives and President Taylor invites her
to formally present her great gift, to place
her hand upon it, affectionately bid it good-
bye and commend it to its good purpose as
a permanent part of this cabinet, we will
realize that for all time it will bear the
actual finger-prints of the discoverer of
rati i tun, as the Pasteur crystal model, the
Lister instruments, the Jenner inkstand and
the Rush watch do of their former owners.

If I were asked again, "Will it not feel
homesick"'" I would say: "Let us imagine
some future evening here in this beautiful
hall after the scientific audience has gone,
the lights are turned out, the janitor has
made his rounds, locked the door and gone
home, the moonlight streaming in the tall
windows near the case, and the Liberty Bell
in Independence Hall has struck midnight
by some fairy hand. Then the little fairy
spirits that stand guard over these memen-
tos awake. From the Curie instrument one
stretches out his hand and touches another
of one guarding the Pasteur crystal, grasps
it and a chatter in French breaks the silence.
This wakes up the sprightly guardian of
Lister's instruments and Jenner's inkstand,
who join in an international parley at

SPECIAL MEETING IN HONOR OF M UDAME CURIE

which i tic American spirit of Dr. Rush
(liinl)s out of his invisible retreat and they
all (lain e about and nan ate theii u < mdci I ul
past.

" I hen one can see as the dawn breaks
ihe\ all hide again invisible. I he janitor
unlocks the library and vistors come to
study and pay homage to the great names
we all worship.

" I his historic instrument will not be
lonely."

()l all the galaxy of stars illuminating the
past, none commands greater reverence than
Pasteur. 1 he portrait of him most treasured
h\ the Institute has been perpetuated in a
fine large etching presented to us by Cal-
mettc and brought over by Dr. Keen. It is
in beautiful contrast as showing the fine
si u nit \ of his later life to the earliest
known portrait of which 1 find a copy in
Dr. Weil Mitchell's collection in youi li-
brary. This early one is so rare that few
know of it. That early face is the pure
scientist, typified in a quotation which is
a tribute to his character, taken from one of
his letters to his young love in offering his
life to her. He says:

"Time will show you that below my cold,
shy and unpleasing exterior there is a heart
full of affection for you."

Perhaps the main influence of this memo-
rial case will be a tendency to raise the tone
pi the life of our future professional men
by spreading before us some of the attri-

butes of the highest lives devoted to the
healing art, whose hearts have been com-
pletely devoted to this fruitful work.

There exists today, as always, a com-
mercial tendency which needs to be neu-
tralized. It is the same in business. One
reads on the advertisement boards of a busi-
ness college this legend, "We turn time and
brains into money." What sacrilege! Time,
given in our short lives for some worthier
purpose "lime is Mine, 1 will iepa\,"
s.i it h the Lord. And brains, to search out
the Creator, if happily we may find Him.

Is there no greater aim than making
money? Let those who have so given their
lives turn their accumulated wealth into
the treasures of our laboratories and uni-
versities, and, after all, find the joy of serv-
ice. Already fortunes are being diverted to
science.

It has been a heai twai ming sighl to see
the universal response of the women of our
broad land, poor and rich, contributing as
they could to the fund to equip Mme.
Curie's laboratory. The great good that has
emanated from them is sure to be now con-
tinued.

# # #

At the close of Dr. Abbe's address,
Madame Curie arose and placing her hand
on the apparatus said, "I am glad to present
this instrument to so distinguished a
society."

THE CUSTODIANSHIP OF

RUSH TENNER' PASTEUR
LISTER' CURIE
MEMENTOS

IN THE CABINET OF
THE COLLEGE OF PHYSICIANS
OF PHILADELPHIA

HELD IN SUCCESSION BY
REPRESENTATIVE MEMBERS OF THE
MEDICAL PROFESSION OF THE
UNITED STATES

THE CUSTODIANSHIP CABINET OF
THE COLLEGE OF PHYSICIANS

THE COLLEGE OF PHYSICIANS

PHILADELPHIA

THE CUSTODIANSHIP CABINET

OF THE COLLEGE OF PHYSICIANS

THE College of Physicians of Philadelphia has represented
the lofty purpose and spirit of scientific medicine since
the early days of our country, and seems the fitting repository
of historic souvenirs, the nominal custodianship of which is
an honor — worthy of our best men.

The spirit which actuates the lives of men of great accom-
plishments, is epitomized in these five representative scientists
and physicians to whom this is dedicated.

The compelling force in all may be said to be: intensive
preparation; unlimited resourcefulness in wor\; close and
exact observation; strong conviction of right; defiant bravery;
idealism; culture; religious faith; humanitarianism; and edw
cative zeal.

Rush said, " I ma\e everyone whom I meet contribute to my
improvement."

Jenner wrote, "I am not surprised that men are not than\-
ful to me, but I wonder that they are not more grateful to God,
for the good which He has made me the instrument of con*
veying to my fellow creatures."

Pasteur said, "Opportunity comes to him who is prepared."

Lister said, "The scientist's public life lies in the wor\ that
is his."

Mme. Curie says, "I desire only to teach."
In the belief that such exalted lives are found in every de-
cade, often in humblest surroundings, it is probable that the

man at the top will be more able to discriminate among corn-
temporary wor\ers, and to choose one whom he considers the
exemplar of such traits.

The first chosen custodian of these mementos, Dr. Weir
Mitchell, conceded by all to be such a representative spirit,
was as\ed to name a successor, embodying the highest type of
physician and educator, in productive scientific wor\. He
chose Dr. Simon Flexner, of the Rockefeller Institute, ~Hew
Tor\. He followed the provision that the incumbent custodian
should choose his successor from the ran\s outside his own city.
Dr. Flexner, after three years, as\ed to be permitted to pass on
the honor during his lifetime, and chose Dr. Wm. H. Welch,
of Baltimore, whom he considered the most worthy representa-
tive in our time. Dr. Welch has accepted the honor, saying,
"'Why, it's li\e the 'Gold-headed Cane,' " and has promised
to choose a successor.

At longer or shorter intervals, the choice must fall on men,
not necessarily \nown by popular acclaim or professional s\ill,
but always by great humanitarian accomplishments and un'
tiring wor\.

The letters of acceptance with portraits of each custodian
preserved in the boo\s in this cabinet will ma\e, in time, an
unmatched collection of distinguished autographs of notable
American physicians.

A sufficient fund has been given with this case of mementos,
to perpetuate and enhance the collection. Thus it will always
be an honor to be chosen custodian, either by the incumbent,
or in default of such choice, by the Council of the College of
Physicians.

THE CASE AND MEMENTOS

lHli.ii.iJ

WITH BOOKS CONTAINING PORTRAITS, ILLUSTRATIONS,
AUTOGRAPH LETTERS AND BIOGRAPHIC NOTES, WITH
THE CONDITIONS OF THE CUSTODIANSHIP

I A-

First Custodian — Dr. Weir Mitchell, Philadelphia, 1910-17.
Second Custodian — Dr. Simon Flexner, New York, 1917-20.
Third Custodian — Dr. William Henry Welch, Baltimore, 1920-24.
Fourth Custodian— Dr. W. W. Keen, Philadelphia, 1924-28.
Eifth Custodian — Dr. Wm. J. Mayo, Rochester, Minnesota,
1928-39.

THIS CUSTODIANSHIP WAS FOUNDED BY ROBERT ABBE
OF NEW YORK CITY, ASSOCIATE FELLOW OF THE
COLLEGE OF PHYSICIANS, PHILADELPHIA

DEDICATION

■. I HERE is an ethical foundation stone in the
education of a medical man, which is just
as essential as book knowledge, and lab'
|Wfj& oratory work. The subtle power of the
* , ro names which rank high in our profession,
makes an impression upon the student's early manhood
and unfolding character. A virile force pervades him when
he has the high example of character held before him.

There are some names in our profession, which reprc
sent our medical ancestors, as it were, whose very spirit
evokes a thrill when we come into actual touch with their
belongings, such as no ordinary thing inspires. The actual
objects that felt the living touch of the great Pasteur,
Jenner, Lister, Rush, Curie, and others of like fame, are
more sacred to us, than the cloak of Charlemagne or the
cocked hat of Napoleon, for example. It needs not more
than one verified article which was the intimate personal
property of such human beings to visualize for us the
whole character of the owner, and thrill the observer. Who
would not glow with interest and sympathy when he sees
the instruments used by Lord Lister in the early days of
his work and triumph? Who would not travel a thousand
miles to see and hear the immortal Pasteur, who put into
action those compelling thoughts evolved out of his giant
brain? Recently, in this decade, a new light has radiated
on science from the Curie laboratory in Paris, which has not
only revolutionized the conception and calculation of the
forces of nature, but has put into the hands of our profes'
sion a weapon, hitherto unsuspected, to help control disease.

BENJAMIN RUSH
[1745-1813]

BENJAMIN RUSH

THE first of the five thrilling mementos in our cabinet
is the beautiful watch of Dr. Benjamin Rush. Though
there were doctors scarcely less cultivated and devoted, who
dignified the early records of American medical service, yet, by
common consent, theachievementsof Dr. Rush are preeminent.

SHOE BUCKLE WORN BY DR. RUSH [ACTUAL SIZE]

In his day the seal of great deeds was stamped on our
country's history by Washington, Adams, Hamilton, Frank-
lin, Lafayette and a score of other noted patriots. Dr. Rush
was the intimate friend of these, and of all the savants of
his day. His name has come down to our time as, per-
haps, the most representative medical man who combined

culture with patriotism, scientific zeal with literary at-
tainments, and religious devotion, and an indomitable
courage with unwearied power for work.
This watch is inscribed:

BENJAMIN RUSH
SIGNER OF THE DECLARATION OF INDEPENDENCE
OBIIT 1813
RICHARD RUSH
OB. 1859
BENJAMIN RUSH

It must have been his most highly prized personal posses-
sion and his constant companion. Even at this day, after a

THE WATCH OF BENJAMIN RUSH

century and a half, it is a perfect time-keeper. It was his guide
in all appointments, punctually kept, and must have been

under the eyes of many great men of the day; perhaps it
witnessed the last hours of national heroes.

One feels a thrill when holding it in one's hand, and, as it
ticks the seconds, one is drawn back in fancy, to the days
when the same sound was heard by ears now deaf. It inspires
in the visitor today, emulation of the spirit of its owner.

Another heirloom, a silver shoe buckle, set with brilliants,
worn by Dr. Rush, has been given to this cabinet by his
great grand-daughter, Catharine Rush Porter (Mrs. J. Biddle
Porter). It suggests the gallant and chivalrous coterie of
gentlemen who surrounded the first president of our
country.

EDWARD JENNER
[1749-1823]

EDWARD J EN N MR

THE second memento in our cabinet is an inkstand, one
of the personal possessions of Edward Jenner. His
name is honored by the English-speaking peoples not more
than by the civilized world.

This inkstand came into the possession of our loved Weir
Mitchell, who used it reverently for years, and presented it to
the College of Physicians at his death.

It has a peculiar charm, because it stands for literary effort,
besides signalizing the long, weary fight Jenner made by his

THE JENNER INKSTAND

writing and speeches, to obtain recognition for the principle
of cowpox vaccination against smallpox.

We realize the power for good of one indomitable will in a
life-long fight to overcome prejudice and obstinate antago-
nism of friend and foe. We think of the enormous uplift of

civilized communities, from India and Russia through
Europe to America, when freed from the dread scourge of
smallpox.

The lesson of Jenner's life may be epitomized as a serious,
thoughtful, conscientious, studious development of one
fundamental discovery, a fact that was the kernel of a newly
revealed principle in medical practice — vaccine therapy. To
him it was revealed truth, and, as such, having the conviction,
he gave up the best of his life to defending and spreading it
broadcast. On every side he met opposition, which he broke
down with indomitable determination.

THIS LOCK OF JENNER's HAIR, PRESENTED TO
THE COLLEGE OF PHYSICIANS BY WILLIAM OSLER,
MARCH 1, 1893, BEARS THE FOLLOWING INSCRIP-
TION ON THE BACK OF THE LOCKET. "THIS HAIR
WAS CUT OFF AFTER EDWARD JENNER's DEATH
BY MRS. AUSTIN OF SLONE, HIS NIECE, AND
HANDED BY HER TO ME. W. R. AWDRY, JULY 29,
1892." BERKELEY, GLOUCESTERSHIRE, (ENGLAND).

JOSEPH LISTER
[i827'i9i2]

JOSEPH LISTER

OF Lord Lister we are the fortunate possessors of two
valued souvenirs. The first is a small case of surgical
instruments used by Lord Lister. It was a part of his equip-
ment, both in Glasgow and in Edinburgh, while he was
developing his principles of antiseptic surgery, and, in
London, where he was invited to take the chair of surgerj
in Kings College, but where he found the greatest difficulty
in advancing his work.

It is almost impossible to find any article personal to him
outside of the Lister Museum, but, through the kindness of

A SMALL CASE OF INSTRUMENTS USED BY JOSEPH LISTER

[name PLATE INSCRIBED "j. lister"]

Sir Rickman Godlee, a nephew of Lord Lister, and his
biographer, we have been able to secure these two veritable
articles. The box of surgical instruments has Joseph Lister's
name on the cover of the case. They must have been used by
him for many years. The instruments are of the make of

lister's original tubes for tests of lactic acid fermentation

"Young" and "Borthwick, Edinburgh," and "Weiss,
London."

Many of us have had the gratifying memory of seeing
Lister operate, and will be impressed by the conscious sensa-
tion, that, perhaps, these very instruments were seen by us
in his hands. How near it brings us to the man, who, by
patient labor, developed the Listerian principles!

The second souvenir, full of human interest is a group of
six small glass tubes, each with a thimble shaped glass cover,
fitted in a rack made of four pieces of cut off glass tubing,

wired together by silver wire, which is further twisted, rope
fashion, about the tubes to hold them together upright.

This rack is placed on a five inch square plate glass, and
covered by a bell glass.

In his earliest private researches he fashioned these with
his own hands, to accommodate it to a "hot-box" for ster-
ilizing at 300 , before introducing into the six tubes fresh
milk, either sterile, or slightly contaminated, to demonstrate
that if dust can be prevented from getting access to the
putrescible fluid, infection is impossible.

He used these tubes in his lectures, and for his own satisfac-
tion, to show that milk could be kept sweet till it dried up.
All these tubes contain the very remnants of his experimental
fluids, some with and some without mould.

These identical tubes are illustrated in his biography
(Godlee, p. 267), and in his "Collected writings" p. 302.

LOUIS PASTEUR
[1822-1895]

LOUIS PASTEUR

HE fourth souvenir is of the great Pasteur. By singular

good fortune we have something characteristic.
Precious to the hearts of the French people is everything
connected with the life of Pasteur. This souvenir was
generously given to the College of Physicians of Philadelphia,
by Calmette, of the Pasteur Institute, formerly assistant to
Pasteur, and transmitted by the hand of Dr. W. W. Keen.

It would be diflicult to acquire anything more precious than
this model of a crystal, which Pasteur made, labelled, and
mounted with his own hands, to use before his sceptical audi-
ences in demonstrating the nature of crystals from wine fer-
mentation. The chemistry of this had been a stumbling block
to scientists. No explanation of why one of two tartrate
crystals, showing identical analysis, turned polarized light to
the right, while the other turned it to the left.

Pasteur demonstrated his views with this model, in strenu-
ous debate with his adversaries in 1862. This research and
demonstration won him added renown as a chemist, and was
the key to his future work. He unravelled the mystery of the
cause of putrefaction and fermentation, and, in his own
words, speaking to the Emperor, he said, "all my ambition is
to arrive at the knowledge of the causes of putrid and con-
tagious diseases" (1863).

Two years later, Lister first read Pasteur's writings proving
that putrefaction was of germ origin, and made his first
demonstration of the efficiency of carbolic acid in surgery
(March, 1865). He gives all credit to Pasteur for his great

discovery. The world is indebted to Lister, however, for his
undaunted bravery, his pioneer advocacy and application of
this principle to surgery in the face of universal opposition.

In that year Pasteur began an intensive study of the cause
of the decadent vintages of France. The outcome of this was

a proof that deterioration of wine with
deposition of tartrates, was due to a
low-grade bacterial fermentation,
which could be arrested permanently
by heating wines sufficiently to kill
bacteria, but not hot enough to alter
the wine.

One after another followed Pasteur's
intensive researches into difficult prob'
Iems of national importance. He was
first called upon to solve the mystery
of the silkworm disease which was
ruining the silk industry of France.

Pasteur solved the problem, found
a remedy, and restored an industry.
I le then attacked the disease anthrax,
which was ravaging the herds of cat'
tie and destroying the leather indus'
try. He demonstrated again the bacil'
Ius of anthrax, and furnished the cure for the disease. Hog
cholera and chicken cholera then claimed his attention.
Again he put his finger on the weak spot, and announced a
cure. Finally the triumphant conquest of hydrophobia was

MODEL OF A TARTRATE
CRYSTAL MADE AND USED
BY PASTEUR. HEIGHT 8
INCHES

proclaimed. Though the bacterium which causes hydropho-
bia has not yet been discovered, its existence is assumed,
and, based on that assumption, his remedy — the only suc-
cessful remedy — has been applied.

His researches and proofs banished forever the claims of
most of the scientists of his time, in favor of spontaneous
generation of life.

MME. MARIE CURIE

MME. MARIE CURIE

THE fifth memento is an instrument of precision,
devised by Prof. Pierre Curie, at the Sorbonne in Paris,
and used by him and by Mme. Curie. It was employed to
determine the strength of electron discharge from radium,
which Mme. Curie had just discovered by an ultra-scientific
piece of detective work, little less than a romance.

This instrument illustrates, also, another discovery which
Prof. Curie was elaborating before that time, namely, the fact
that crystalline substances, when compressed or expanded,
emit electrons, due to the strain put upon them. In this
instrument there is a long slice of a quartz crystal, held by
one end and weighted at the other. An electroscope, placed
opposite the face of the crystal records the discharge of
electrons, in exact proportion to the weight put upon it.
This is known as the "Quartz-piezo-electric" apparatus.
This very instrument was used by the discoverer of radium
in her early work, and is presented to the College of Physi-
cians by Mme. Curie in response to an appeal for a souvenir
of her work. It may almost be said to be the first instrument
ever made actually to weigh, as it were, the smallest divisions
of the atom, the electrons. To view this instrument is to be
enthralled by the spirit of research which its personality
inspires.

Translation* of Mme. Curie's Description of the
Apparatus She Gave to the College of
Physicians, Philadelphia
In this apparatus is utilized the property which crystals of
quartz possess of acquiring an electric polarization following
a deformation.

This phenomenon of " Piezo electricity" thus manifested
in quartz was discovered by Pierre and Jacques Curie and

MME. CURIE SEATED BEFORE A MODIFIED QUARTZ'PIEZO ELECTROMETER (1921 )

recognized not only in quartz but generally in all crystals
not having a center of symmetry.

The lamina of quartz used in this apparatus has a thickness
of about one-half millimeter. Its surface is perpendicular to
one of the three binary axes of the crystal. It is a rectangle
whose shorter side (about fifteen millimeters) is parallel to
the third optic axis, so that the longer side (six to ten centi-
meters) is perpendicular to this axis. The two ends of the
* Translation by Prof. A. W. Goodspeed

lamina are fixed in clamps of whic h one is used to suspend the
lamina while the lower clamp carries a pan in which weights
can be placed. When the pan is loaded there is exerted on the
crystal a tension in a direction at once perpendicular to the
third axis and to the second axis. This tension has the effect
of setting free on the two faces of the lamina quantities of
electricity equal and opposite in sign which it is the purpose
to collect. For this the two faces of the lamina are covered
with tinfoil or a deposit of silver. These conducting armatures
are insulated by grooves placed opposite each other at the
ends of the lamina. One of the armatures is connected with
the earth while the other is insulated. When a weight is
placed on the pan a definite quantity of electricity and of a
given sign is set free on the insulated armature. This quantity
" q" is proportional to the stretching weight F; it is expressed

klF

by the formula q = — where / is the length of the lamina, e
the thickness of it, and k the piezo electric modulus for quartz.

When the weight F is lifted the quantity of electricity set
free on the insulated armature is equal and of opposite sign
to that which is obtained in putting the weight on.

Such a lamina which is really a very constant electric
standard may serve to measure currents of feeble intensity
such as those which are produced in ionization chambers by
radioactive substances. For this purpose the insulated
armature is joined to one of the quadrants of an electrometer
the other one being grounded. The insulated quadrant is also
attached to the source of electricity which produces the
current that is to be measured (for example to the insulated
electrode of the ionization chamber).

One can compensate very exactly the current to be meas-
ured and keep the electrometer at zero by lifting gradually a
weight F put on the pan. The current strength i is given by
the formula i = J, where t is the time measured by a chro-
nometer during which the current i has been compensated
by the raising of the weight F. Thus this current i can be
known in absolute value with great precision.

This way of measuring was used continuously by Pierre and
Jacques Curie in their researches on feebly conducting bodies.
I used it afterwards in my researches on the radiation from
compounds of uranium and of several other substances.
Later we have constantly used it, Pierre Curie and I, in the
measurement of radioactivity made necessary by the new
method of chemical analysis which has served us in the
separation of the new radioactive substances, radium and
polonium.

It can be concluded then that this method of measurement
has rendered very great service.

The piezo-electric quartz apparatus is still continuously
used in the Curie laboratory. It is employed by the investiga-
tors and by the students who easily learn its use. The
magnitude of the currents which can be thereby measured
varies within wide limits.

The apparatus which I offered to the Cabinet of the
College of Physicians of Philadelphia is one of the first
models made. It is one of two which were used by us in our
associated work during the first years of our researches on
radioactivity.

Venerable But Vigorous: The College
of Physicians 1

7iv LUCINDA P. R< >SJ

Till large, red-brick building on 22nd
Street, just below M.uket, holds
within its walls a profusion of won-
derments, including a museum, a library,
the meet in» hall for a soc iety that has been
in existence since 1787, and oil paintings
by Gilbert Stuart, Eakins anil Sargent. But
few Philadelphians outside the medical and
pharmaceutical professions have visited
The College of Physicians of Philadelphia
or know anything about the wealth of in-
teresting material housed within its build-
ing.

And without, for even the garden beside
the building is not an ordinary one, but a
medicinal herb garden (Figure 1). By tak-
ing .1 walk along its paths, you find out that
Mother of Thyme is a cure for nightmares,
Rosemary for asthma, and should you want
to induce perspiration, try a bit of Lemon
Balm. Responsible for maintaining this
plot of edifying greenery is the Philadelphia
Unit of the Herb Society of America. The
garden is open to the public — they ask only
that you leave it as you find it.

The Mutter Museum, located within the
College building, is a place you may want
to leave the minute you find it. However,
with a strong stomach and strong will-
power, you can spend several hours in the
museum and still not take it all in. The
executive director of the College, Dr. W.
Wallace Dyer, characterizes the museum as
being "unusual in its variety." This seems
like an nuclei statement. Along with the
to-be-expected collections of pickled loeti,

'This article appeared in Delaware Valley
Calendar in September 1908. It is reprinted here
with permission of the Editor-Publisher at the
request of the- Council of The College of Physi-
cians.

2 A free lance writer.

skeletons and skulls are collections of eye-
glasses, shoes and thermometers. More grisly
items include shrunken heads and a wallet
made ol human skin (given l>v an anony-
mous donoi i .

II you are a celebrity seeker, you may
want to look at a piece of John Wilkes
Booth's thorax, the bladder calculi re-
moved from duel Justice- John Maishall,
or the plaster cast of Chang and Eng
Bunker, the famous Siamese twins. I hen
there is the- upper right jaw of President
Cleveland, complete with seveial teeth, or,
for the ladies, Florence Nightingale's sew-
ing-kit.

One thing you're not likely to miss in the
museum's helter-skelter is the skeleton ol a
giant, seven feet six inches tall and simply
labeled as "a young man from Kentucky."
Equally eye-stopping is the bod) of the
"petrified lad" — the adipocere body of a
Mrs. Ellenbogen, which is casually laid out
in the open on a slab in one of the rooms
and more awesome than a mummy in the
University Museum.

Although most ol the museum is con-
centrated in five or six looms, other memo-
rabilia are placed In cases throughout the
building. Particularly notable is the collec-
tion in the second floor hallwav which
includes Benjamin Rush's gold watch (re-
putedly still in working condition): an ink-
stand and lock of hair belonging to Edward
Jenner (the discoverer of vaccination): an
instrument used bv Pierre Curie to study
radioactivity shortly after its discovery,
<alled the "quartz-piezo-electric" and
donated to the College by Marie Curie;
Joseph Lister's carboli< acid spray from his
early days of antiseptic surgery; and a
model ol tartar crystal made by Louis
Pasteur.

243

2! 1

LUCINDA P. ROSE

1. The herb garden of The College of Physicians.

Of these famous men, Benjamin Rush,
signer of the Declaration of Independence,
was the one most intimately associated with
The College of Physicians, heing, in fact,
one of its founders. Other founders in-
cluded John Morgan, William Shippen,
Samuel Dufheld, John Jones — all famous
figures in the early Philadelphia medical
scene.

The College was founded not as a college
in the sense of an educational institution,

but rather as a "collegium" — a society of
colleagues. Its prototype was the Royal Col-
lege of Physicians of London. Fellows of the
College were to be elected "without any
regard to Diversity of Nation or Religion"
according to the words of the founders.

During its early years the College was
often called upon to give advice on public
health matters, especially during the epi-
demics of yellow fever at the turn of the
18th Century. The College still maintains

V1.M.R MU 1 Ut I VK.OKOl s

245

.in at t i \ t- interest in public health. For ex-
ample, recent meetings have included Mil)
jects such as aii pollution and hallucino-
genic drugs.

Now numbering almost I 100 Fellows, the
College provides a common meeting ground
lor all the medical schools, hospitals and
leaders in the medical profession in the
Philadelphia an a. Members inc hide women
as well as men. The endowed monthly lec-
tures are usually published in the College's
quarterly journal. The Transactions and
Studies of The College of Physicians of
I'hiladel()liia. the first issue of which was
pi tnted in 1 1 1 1 x 1 793.

Perhaps most important of all to College
Fellows, as well as to the area's medical pro-
fession at large, is the extensive medical li-
brary maintained bv the College. The li-
brary contains almost a quarter million
volumes and subscribes to .1200 medical
journals in connection with which it pro-
vides scanning, indexing, abstracting and
translating services. It also has a Rare Book
Department, including 416 incunabula
(books printed before 1500) and eight medi-
eval manuscripts.

Started in 1788 with the donation of
twenty-four volumes by John Morgan, the
library now ranks as the third or fourth
largest of its kind in the country. It is used
widely bv medical students, historians,
lawyers, advertising firms, pharmaceutical

and other industrial dims, and many others
who have occasion to do medical research.
It lias Ik i n named a regional medical li
bran, related to the National Library of
Medicine in Washington.

Lining the walls of library, hallway and
meeting room are the over sixty paintings
in the College collection. Most of these are
portraits ol Philadelphia physicians who
were Fellows of the College. Some of the
artists are well-known, including Thomas
Eakins, John Singer Sargent, Thomas
Sully, Gilbert Stuart and Rembrandt Peale.

Many of these portraits are hung in
Mitchell Hall, the large, handsome, wood-
panelled room in which the monthly meet-
ings of the College are held. One Fellow has
described these meetings as the "stuffiest"
he has ever seen; another describes them as
"prestigious." These impressions may be
fostered in pari h\ the fact that those who
preside over the meetings wear academic
robes. In any case, the meetings are con-
sider abl) enlivened by the erudite w ittic isms
of the current President, Dr. Francis C.
Wood, former chairman ol the Department
of Medicine of the University of Penn-
sylvania.

The College of Physicians is a venerable,
but still very vigorous institution, and well-
worth a visit from the medical-information
seeker, the art student, the curiosity seeker
or herb-garden fancier.

246

The Council <>l I he ( olli ge ol Physicians of Philadelphia, 1969

(Left to right) Front How: T. Griei Miller, George I. Blumstein, Francis C. Wood, George
A. Hahn Second Row: Samuel \ Raclbill. David A. Cooper, Elizabeth Kirk Rose, Donald M.
1'illsburv, Gonlon \. French, Esmond R. Long, John L. McClenahan, Alfred M. Bongiovanni,
John H. Gibbon, Jr., Fred B. Rogers, Robert Erwin Jones, Paid Nemir, Jr. (Absent from
photograph) Lcroy E. Burney, Thomas M. Durant, Kendall A. Elsom, Peter A. Herbut,
William P. T. Kellow, Richard A. Kern, Robert S. Pressman, Jonathan E. Rhoads, Truman G.
Schnabel, Katharine R. Sturgis.

247

248

The Staff of The College of Physicians, 1969

(Left to right) Front Row: Mrs. Helen M. Reaney, Mrs. Ella N. Wade, Miss Alberta D.
Berton, Mrs. Beatrice F. Davis, Elliott H. Morse, Miss Olga E. Lang, Mrs. Lisabeth M. Hollo-
way, Walton Brooks McDaniel, 2d. Second Row: Miss Josefa Sereda, Miss Thea Fischer, Gilbert
Bey, Miss Julianne Gable, Mrs. Pearl Stark, Mrs. Catherine Ledwell, Mrs. Juneann Lauder-
bach, Mrs. Marybeth Leary, Alfred G. Lisi, Miss Mildred Gray, Miss Yoshi Nakayama. Third
Row: W. Wallace Dyer, Mrs. Elizabeth Wright, Mrs. Donna Parks, Mrs. Ann Schor, Mrs.
Sarah Caspari, Mrs. Kathryn Miragliotta, Miss Evelyn Huber, Dennis Dougherty. Fourth Row:
Miss Linda S. Frantz, Miss Linda Justice, Mrs. Eleanor Taylor, Miss E. Noami Frazer.
Fifth Row: Miss Anne McGinnis, Miss Dagmar Nemecek, Mrs. Judy Barnes. Sixth Row: Miss
Valerie Suber, Mrs. Rhea Brown, Mrs. Christine Balonis, Mrs. Michele Winters. Seventh Row:
Miss Carol C. Spencer, Mark Mattson, A. Male. Eighth Row: Miss Florence Fritz, Miss Grace
Rupertus, Miss Andrea L. Jancsura, Miss Elizabeth Bertram. Ninth Row: Timothy Phillips,
Mrs. Lynn Langdon, Mrs. Carol Stills. Tenth Row: Miss Margot van Rossum, Miss Lee J.
Tanen, Miss Jean Carr, Carmine Salvato. Eleventh Row: Russell Campbell, James Bolton,
James M. Gavin, Theodore Kolodziejski.

249

New Fellows of The College of Physicians of Philadelphia

Elected 1969

Name

Place/Date of Birth

1. Bannett, Aaron D.

2. Baronofsky, Ivan D.

3. Belmont, Herman S.

4. Birtwcll, William M.

5. Blocklyn, Maurice J.

6. Bryant, Winston M.
Jr-

7. Buchheit, William

8. Chesnick, Reuben B.

9. Cohen, Erwin A.

10. Davidson, Jay H.

♦

11. Denbo, Elic A.

Phila., Pa.
7-12-23

New York, N. Y.
12-12-17

Phila., Pa.
3-13-20

Ridley Park, Pa.

9- 19-35
Paris, France

10- 14-12

Brooklyn, N. Y.
7-9-29

Donara, Pa.
10-14-33

Haddonfield, N. J.
1-15-09

Phila., Pa.
4-8-25

Phila., Pa.
4-12-18

Camden, N. J.
10-3-08

12. Desiderio, Vincent C.

13. Dolphin, John M.

14. Dzwonczyk, John, Jr

Phila., Pa.
7-4-26

Mahanoy City, Pa.
11-28-23
Dunmore, Pa.
10-22-27

Medical School

Present Position

Jefferson '46

Marquette U.
'43

U. of Pa. '43

Temple U. '60
U. of Pa. '37

Meharry '60

Temple U. '60
Jefferson '36

U. of Pa. '48

Temple U. '43
Jefferson '33

Hahnemann
'53

Hahnemann
'47

Hahnemann
'54

Assoc., Surgery & Chief Consul-
tant, Vascular Surgery, Einstein
(N); & Head, Organ Transplan-
tation Unit, Einstein (N).
Chairman, Dept. Surgery, Hahne-
mann; Research Assoc. Scripps
Clinic and Research Foundation.
Prof. & Head, Section on Child
Psychiatry; Member Advisory
Committee on Child Planning to
State of Pa. Commissioner on
Mental Health.
Section, Rheumatology & Asst.

Prof. Med., Temple.
President, Med. Staff, Crozer-
Chester Hosp., Dept. Radiology,
Crozer-Chester and Taylor Hosps.
Surgeon, Ophthal., Mercy-Doug-
lass; Instr., Ophthal. Temple;
Asst. Surgeon, Wills; Ophthal..
St. Christopher's.
Instr., Neurosurgery, Temple; Asst.
Attending Neurosurgery, St.
Christopher's.
Assoc. Radiologist, VA Hosp.;
Radiologist, Camden Cyt. Gen &
Camden Cty. Chest & Camden
Cty. Psychiatric Hosps.
Clinical Instr., Temple; Adjunct,
Einstein (N); Staff Surgeon at
Rolling Hill, Oxford and Ken-
nedy Memorial Hospitals.
Assoc., Gastroenterology, Einstein
(N); Director to 1968 Med. Edu-
cation at St. Luke's & Children's.
Chief Neuropsychiatrist, Cooper
Hosp.; Chief, Neurology, W.
Jersey Hosp.; Assoc., Neurology,
Grad. Hosp.; Assoc., Psychiatry,
Phila. Psychiatric Center; Assoc.,
Neurology, U. of Pa. Grad. Sch.
Med. & Jefferson Med.
Sr. Clin. Instr., Gastroenterology,
Hahnemann; Assoc., Int. Med.,
St. Agnes.
Staff & Assoc. Prof., Pathology,

Hahnemann.
Instr., Surgery, Hahnemann; As-
soc., Surgery, Fitzgerald Mercy;
Attending in Surgery, Miseri-
cordia.

250

NEW FELLOWS

251

Name

15. Ganz, Michael A.

16. Gardiner, George C.

17. Gehring, David A.

18. Gellhorn, Alfred E.

19. Goldman, Leonard

20. Haase, Gunther R.

21. Hanson, Stephen M.

(Non-Resident)

22. Harrell, George T.,

Jr. (Non-Resident)

23. Hollender, Marc

24. Kain, Thomas M., Jr

25. Kissick, William L.

II (Non-Resident)
27. Klinghoffer, Leonard

28. Koblenzer, Peter J.

Place/Dale o] Birth

Medical School

Hartford, Conn.

U. of Ottawa

10-20-34

'60

Bridgeport, Conn.

Tufts U. '61

8-17-35

Bryn Mawr, Pa.

U. of Pitts-

12-6-30

burgh '56

St. Louis, Mo.

Washington U.

6-4-13

(lit 1 filllc^

'37

N.J.

Univ. Western

3-4-30

Ontario '55

Chemnitz, Germany

'^Q-Ludwig"-

9-30-24

\T 21 IT 1 mill TTK

I I Tl 1 \'fr<:t T t

Munich

Los Angeles, Calif.

8-18-24

'48

Washington, D. C.

Duke U. '36

6-16-08

Chicago, 111.

U. Illinois '41

12-19-16

Camden, N. J.

Jefferson '43

2-16-17

Detroit, Mich.

1 die vj /

7-29-32

Phila., Pa.

U. of Pa. '42

5-6-15

Phila., Pa.

1 1 -30-27

Munich, Germany

London '51

12-6-22

Present Position

Staff Psychiatrist, Sidney Hillman
and Gloucester Cty. Psychiatric
Centers.

Instr. Med., U. of Pa. Med; Asst.
Attending Physician, PGH; Jr.
Attending Physician and Chief,
Inhalation Pulmonary Function,
Mercy-Douglass Hosp.

Attending, Int. Med., Underwood
Memorial (Woodbury); Consul-
tant in Cardiology, Elmer Com-
munity Hosp. (N. J.) ; Staff, Edge-
wood Div., W. Jersey Hosp.
(Berlin, N. J.).

Dean and Director and Prof., Medi-
cine & Pharmacology, U. of P
Med.

Asst. Prof., Surgery, Temple

Sr. Attending Physician, PGH;
Dept. Neurology, Temple.

Pathologist, Coatesville Hosp.; In-
str., Pathology, Temple.

Dean, and Prof. Med., Pa. State U.
and Dean, Hershey Med.

Prof., Psychiatry, U. of Pa. Med.

Chief, Dept. Med. & Assoc., Cardi-
ology, Cooper Hosp.; Asst. Prof.
Clin. Med., Jefferson; Attending
Staff Physician, Our Lady of
Lourdes.

Prof. & Chrmn., Dept. Community
Med., U. of Pa. Med.; Appa-
lachian Regional Commission
Health Advisory Committee;
Sloan Inst., Cornell U. faculty;
World Health O., advisor; Con-
sultant, Social Rehabilitation
Service (MEDICAID).

Assoc., Staff, Monroe Cty. Gen.
Hosp. (Stroudsburg)

Assoc. Prof., Orthopedic Surgery,
U. of Pa.; Adjunct Prof., Ortho-
pedic Surgery, (N) Einstein.

Assoc., Pediatrics & Derm., U. of
Pa. Grad. Sch. Med.; Assoc.,
Physician, Children's & Rancocas
Valley Hospitals; Assoc. Physi-
cian, Burlington Cty. Memorial
Hosp.; Consultant, Pediatrics
Pa. Hosp.

252 NEW FELLOWS

Name

Place/Dote of Birth

Medical School

Present Position

29. Lentz.JohnW.

Phila., Pa.

U. of Pa. '37

Chief, Dermatology, Lankenau;
Asst. rrot. Dermatology, Jener-
son Med.

30. Lcto, Francesco

Catanzaro, Italy

U. of Naples

Adjunct Prof., Int. Med., Einstein

7-20-25

'55

(N); Assoc. Prof., Int. Med., St.
Agnes.

31. Lightfoot, William P.

Pittsburgh, Pa.
9-12-20

Howard '46

Assoc. Prof., Surgery, Temple

32. Mallin, Aaron W.

Phila., Pa.
10-16-13

U. of Pa. '39

Assoc., Neurology, U. of Pa. Med.;
Instr., Ncur. & Psych., U. of P.
Grad. Sch. Med. ; Chief, Neuro-
psychiatry, Mercy-Douglass &
Amer. Oncologic Hosps. ; Neu-
rologist, Univ. Hosp. at PGH &
Einstein; Neuropsychiatrist,
Grad. Hosp; Psych., Phila. Psych.
Cntr. & Northwestern Mental
Health Center.

33. Mansure, Frank T.

Lansdowne, Pa.
7-24-26

U. of Pa. '53

Out-patient Physician, Prcsby-
terian-U. of Pa. Med. Cntr.

34. Mansure, Patricia R.

Phila., Pa.

\\J-ZZ-Z\3

Woman's '55

Asst. Medical Director, Fidelity
Mutual Life Insurance Co.

jj. Marks, oerald

Brooklyn, N. Y.
4-14-25

Jellerson 4y

Asst. Surgeon & Instr., Surgery,
Jefferson Med.; Asst. Chief of
Surgery, PGH; Consultant, Proc-
tology, Coatesville VA Hosp.

36. Morris, Robert G.,

Winston-Salem, N. C.

Howard '48

Director, Radiology, Mercy-Doug-

Jr.

4-9-24

lass; Acting Med. Director,
Mercy-Douglass.

37. Myers, Eugene N.

Phila., Pa.
1 1 -27-33

Temple U. '60

Asst. Prof., Otolaryngology, U. of
Pa. Med.; Attending in Oto.,
Presbyterian-U. of Pa. Med.
Cntr.

38. Rawnsley, H. M.

Long Branch, N. J.
1 1 -20-25

U. of Pa. '52

Acting Dir., Clinical Research, U.
of Pa. Med. ; Member, VVm. rep-
per Lab.; Consultant, Clinical
Path., Phila. Naval & VA Hosps.;
Assoc. Prof., Clin, rath., U. ot
Pa. Med.

39. Relman, Arnold S.

New York, N. Y.
6-17-23

Columbia '46

Prof, and Chairman, Dept. Med.
U. of Pa. Med.; Chief of Med.
Service, U. of Pa. Hosp.

40. Robinson, Nathaniel

St. Matthews, S. C.

Marquette '54

Med. Consultant, Psychiatry, PGH;

M.

7-20-25

Director, Med. Clinics & Sr. At-
tending Physician, Mercy-Drug-
lass Hosp.

41. Rodgers, Robert A.,

E. Liverpool, Ohio
4-17-25

Hahnemann

Asst. Obstetrician - Gynecologist,
Pa. Hosp.; Assoc., Obstet.-Gyn.,
Underwood Memorial Hosp.
(Woodbury) .

42. Roediger, Paul M.

Princeton, N. J.
6-30-32

Jefferson '58

Director, Med. Education and Asst.
to Chief of Staff, Abington.

43. Rosato, Francis E.

Phila., Pa.

Hahnemann

Assoc., Surgery, U. of Pa. Hosp;

6-2-34

'59

Consultant in Surgery, VA; At-
tending in Surgery, PGH.

NEW FELLOWS

253

Name

Place/Date of Birth

Midical School

Present Position

44.

Rowland, Lewis P.

Mew Vnrl- N V
1 N ( W I OI K , 11 . I .

8-3-25

Yale '48

Pt"(»f R.' f!h a i rn 1 a ti N*Mirnlni'V 1
l I \)i . tx UUWI 1 1 1 <i 1 1 , i^t. m kji itf^ y , \J .

(if Pa \/ff'ri ■ AttrnfliiMr NfMiroln-

gist, Columbia-Presbyterian Med.
Center

45

Schaedlcr, Russell W.

T T 1 1 Ti *> ! rl Pa

i l . 1 1 1 1 ' M i a.

JcfTerson 53

1 K-(U1 , 1 ' 1 . 1 IV 1 1L. I KjiJ 1 1 1 ■ 1 V OC I I Ul ■

W.

12-17-27

\1 i r* r ol ii ol of* v I #* rcon rvl f*H

46

Sewell, Edward M.

Phila., Pa.
5-21-23

U. of Pa. '47

Sr. Physician & Chief, Chest Dis-
eases, Children's; Asst. Prof.,
Pediatrics, U. of Pa. Med.

47.

Silberberg, Donald

W ;i ch i iict f on 1) \.

T of \A irhifran

Assoc. Prof., Neurology, U. of Pa.

H.

3-2-34

'58

Med.; Consultant, Children's &
VA hosps.; Consulting Neurosur-
geon at Doylestown & Phocnix-
ville Hosps.

48.

Skvcrsky, Norman J.

Phila Pa
i [lli.i, i . i

7-7-15

•\ttf»I10ltl(> lMlVvl/'I'ITl IVl'llthlT'l

. ilHHUlllL; 1 liyMtldll, I CllUUCIdl

Va^r 1 1 1 7\ r X linn Finctpin f^Ji Ri

V dSv Ul "I 0\_v.UUll, 1— < 1 I J a LC 111 \ 1 'I / oc

Moss Rehabilitation; Clinical

A cct Prnf oi vJ\ ft\ i/'riiol/*' 1 'on -
\ 1 I I Ul . Ul IVltU, , 1 ' ...\>.< , V-^Ull"

siil t 'in t Pni 1 9 1,/t i 'a I r i r* it* nl/r
Ml .I.M. I M 1 . . 1 v.J ( 1 . . 1 , 1 t v_vt.. Hi' I

49.

Stewart, W. Wayne

L-J ti y lull) V^DIU

T-I ^inn/*ui Qnn

n .iiiii' 1 1 1 . 1 1 1 1 1

R ^cf^rrn T* f*l I ow T inlo**n;*ii - C'on -

10-31-17

'43

sultan t Industrial Med. Ch ester -
Crozer; Staff, Hahnemann.

50.

Taylor, W.J. Russell

Winnipeg, Manitoba,

U. ofManitoba

Assoc. Prof., Hahnemann; Director,

Canada

'56

Clinical Pharmacology -Toxi-

5-6-30

cology, PGH.

Waugh, Bascom S.

Glade Springs, Va.
12-9-08

Meharry '35

Assoc., Clinical Med., Jefferson;
Director, Stroke Rehabilitation

Pnnnpr T~i ocn

52.

Weibel, Robert E.

r q ti t n n l-* q

- ■ i i . 1 1 1 1 ( 1 1 1 , r a.

12-9-29

TT nf Pa "i"!

App nr P^ i riisitrtr , c II ot P n \j1 f*o
. »;>:» UC. 1 CUlall ILd, vJ. Ul 1 a. ivi CU. ,

Pediatrician, Bryn Mawr & Lan-
kenau; Assoc. Physician, Chil-

U I V. 11 3 1 lUbU.

53.

Whitman, Mark A.

Phila., Pa.

Hahnemann

Chief of Service, Germantown

6-4-22

'47

T4 ncn AftpnHinn" Pf*H i n t r ir?

Chestnut Hill; Sr. Instr., Pediat-
rics, Hahnemann Hosp.

54.

Williams, James R.

Bryn Mawr, Pa.
4-21-24

Meharry '55

Director of Pathology, Mercy-
Douglass Hosp.

55.

Wouters, Freerk W.

Atlanta, Georgia
9-23-28

Emory '53

Assoc. Clinical Psychiatrist, Jeffer-
son; Staff Psychiatrist, Friends
Hosp.; Consultant, St. Vincent's
Hosp.

56.

Yanoff, Myron

Phila., Pa.
12-21-36

U. of Pa. '61

Assoc. Ophthalmology, U. of Pa.;
Asst. Ophthal., Children's & VA
Hospitals.

Memoir of Delazon Swift Bostwick
1893— 1968*

By HERBERT J. DIETRICH, JR., M.D.

DELAZON Swift Bostwick, elected a
Fellow of The College of Physicians
of Philadelphia in 1936, was born
on November 30, 1893, in Sheridan, Wyo-
ming, the son of a Congregational minister.
He died November 27, 1968, a few days be-
fore his 75th birthday, at Methodist Hos-
pital, Philadelphia, with which institution
he was closely associated throughout his en-
tire professional life, which spanned 47
years.

Following his graduation in 1921 from
the School of Medicine of the University of
Pennsylvania, Dr. Bostwick interned at
Methodist Hospital where he then served
four years as chief resident physician and
surgeon. He thus acquired a broad knowl-
edge of general medicine and surgery, which
was always apparent in the high quality of
his later work in the specialty of otolaryn-
gology. From 1926 onward, he was continu-
ously associated with the Department of
Otolaryngology, through successive staff ap-
pointments to that of Chief of the Depart-
ment; he had the rank of Emeritus Chief at
the time of his death. He was also Associate
in Otolaryngology at the Hospital of the
University of Pennsylvania and School of
Medicine.

Dr. Bostwick had tremendous respect and
admiration for his seniors, and he counted
it a high privilege, in the best Hippocratic
tradition of medicine in this city, to work
under such stalwarts as the late Dr. Walter
Roberts, one of the very top otolaryngolo-
gists of his day — or any day for that matter.
Equally, his personal relationships with his
peers, residents, nurses, interns and admin-
istrators were characterized by sincere re-

* Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

spect and unfailing kindness. In turn, they
all became his devoted friends. In memo-
rializing Dr. Bostwick, the Methodist Hos-
pital News said of him: "Dr. Bostwick was
an outstanding physician and will be re-
membered by many for his professional
accomplishments. But at Methodist Hos-
pital he will be remembered above all as a
gentleman — for he was in truth a gentle
man. His gracious manner and unfailing
courtesy will be greatly missed in the insti-
tution he served so well."

In addition to certification by the Ameri-
can Board of Otolaryngology (1932), Dr.
Bostwick was certified by the American
Board of Preventive Medicine (1953) in the
specialty of Aviation Medicine. He was is-
sued a private pilot's license in 1931. He
piloted his own plane and had logged over
4000 hours of flying time.

His skill as an otolaryngologist, coupled
with his love of aviation, enabled him to
contribute measurably to the development
of aerospace medicine. Indeed, he played
a major role in the evolution of this spe-
cialty, serving at various times as a faculty
member of Federal Aviation Medical Semi-
nars where he presented "Otolaryngological
Aspects of Aviation Medicine." He was one-
time President of the Civil Aviation Medi-
cal Association; he was Vice President and
member of the Executive Council of the
Aerospace Medical Association, chairing
and serving on numerous committees
throughout the years and receiving in 1964
the Association's award for outstanding con-
tribution to the art and science of aviation
medicine in its application to the general
field of aviation. In 30 years, he missed only
one national meeting of the Aerospace
Medical Association.

He was internationally known in this

254

MEMOIR OF DELAZON SWIFT BOSTWICK.

255

field, with friends among flying physicians
in every country of the world. In 1959, he
attended the International Congress of Avia-
tion Medicine in Rome and was a delegate
to the Flight Safety Foundation seminar in
Nice.

In Philadelphia, Dr. Bostwick was once
featured on the TV Cavalcade of Sports
program as the winner of the Wings Field
Regatta, an air race scored on speed, effi-
ciency and navigation.

In addition to numerous societies having
to do with Aviation Medicine, Dr. Bostwick
was a life member of the American Medical
Association, the Pennsylvania State and
Philadelphia County Medical Societies, the
American College of Surgeons. He was also

a member of the Union League of Philadel-
phia and the Merion Golf Club.

Dr. Bostwick, having married rather late,
was richly blessed in his wife, Hannah
Stretch Bostwick, who fully shared all of his
interests in life. She was at one time his
nurse anesthetist, equally devoted to the
welfare of the patients. She later became his
enthusiastic companion of fireside, skyways
and fairways.

Delazon Bostwick, as a physician who
figuratively always had both feet on the
ground and as a sportsman who soared
above terrestrial cares, enjoyed it all. He
would have agreed with Robert Louis
Stevenson, who said in The Lamplighters:
"To miss the joy is to miss all."

Memoir of Theodore Cianfrani
1899-1968*

By JOSEPH H. ZEIGERMAN, M.D.

THEODORE Cianfrani excelled in
both art and medicine. It was Erwin
F. Faber of the University of Penn-
sylvania who in 1951 encouraged him to
paint in oil. Since that time, he worked in
one media or another whenever he had time
to spare from his busy practice. Ted had a
vast knowledge of art. He read many books
on the subject and knew the fundamentals
of painting as well as the artistic aspect. He
found it relaxing and fascinating. He has
done medical illustrations, pen and ink
drawings, oils, etchings, water colors and
a handful of pencil sketches. He did all of
them well.

He studied art for a brief period of time,
etching with the late Earl Horter, oils with
the late Paul Martel, a life class with Herr
Heymann in Munich, Germany, a life class
in oils with Joseph J. Coppolino and por-
trait painting with Caesare A. Ricciardi.

Examples of his work hanging in the
School of Medicine of the University of
Pennsylvania are portraits of Dr. Harry
Paul Schenck and Dr. Francis Grant. Por-
traits hanging at Graduate Hospital are of
Dr. William Bates, Dr. Edmund Spaeth, Dr.
Robert A. Kimbrough and Anita Porter
Clothier. He painted a portrait of William
J. Clothier, Sr., which is hanging in the
Hunt Club. He also painted portraits of Dr.
William R. Nicholson and Dr. Barton
Cooke Hirst.

Theodore Cianfrani was born in Phila-
delphia on April 12, 1899 and died on No-
vember 3, 1968. His parents were Domenico
Cianfrani and Emilia Di Giacoma Cianfrani.
He was married in 1936 to Ethel Emoline

• Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

Haas. He attended the University of Penn-
sylvania (1917-9) and subsequently the
School of Medicine of the University of
Pennsylvania (1919-23). He took his intern-
ship at Misrecordia Hospital (1923-4) and
was assistant in Gynecology and Pathology
at Howard Hospital (1924-8). He was As-
sistant in Surgery and Instructor in Surgical
Anatomy at Woman's Medical College Hos-
pital (1924-8). He took post-graduate work
at Doderlein Clinic, Munich, Germany
(1932), and became connected with the
Graduate Hospital and Graduate School of
Medicine, University of Pennsylvania, where
he taught Gynecology from 1928-66 and re-
tired as Associate Professor in Gynecology
and Obstetrics.

He was Chief and Director of Gynecology
at St. Agnes Hospital and Clinical Professor
of Gynecology at Hahnemann Medical
School and Hospital. He was an Associate
in Obstetrics and Gynecology at Pennsyl-
vania Hospital.

He was a Diplomate of the American
Board of Obstetrics and Gynecology, Fellow
of the American College of Surgeons, Fel-
low of the American College of Physicians,
Fellow of the College of Obstetrics and
Gynecology, member of the Philadelphia
County Medical Society (serving on the
Board of Maternal Mortality for many
years), and a member of the American Medi-
cal Association and Pennsylvania Medical
Society. He was the author of A Short His-
tory of Obstetrics and Gynecology and wrote
15 papers in obstetrics and gynecology.
Some of his better known articles are Neo-
plasms in Apparently Normal Ovaries,
Panhysterectomy without Vaginal Cleans-
ing, and Endometrial Carcinoma after
Bilateral Oophorectomy.

256

Memoir of Walter S. Cornell
1877-1969 1

By HERBERT W. CORNELL 2

DR. Walter S. Cornell, for 31 years
Director of Medical Services for the
Philadelphia schools and later the
(unsalaried) head of the Philadelphia
Public S< hool Health Fund, died at the age
of 92, on March 21, 1969, in the Presby-
terian Hospital of Philadelphia after an
illness of a few weeks. He will be especially
remembered for his work in the field of
public health and school hygiene.

Walter S. Cornell was born in Phila-
delphia on January 3, 1877, and was grad-
uated from the then recently founded
Northeast High School in 1893. At the time
of his death, he was the sole surviving mem-
ber of the school's first graduating class. He
entered the University of Pennsylvania,
receiving the degree of Bachelor of Science
in 1897 when he had the memorable ex-
perience of being on the same platform as
his father, Watson Cornell, a Philadelphia
school principal, who received a Ph.D.
degree in that same ceremony, and who, at
the time of his death in 1902, was State
Director for Pennsylvania of the National
Educational Association.

Walter S. Cornell continued at the Uni-
versity of Pennsylvania, entering the School
of Medicine in 1897, receiving his M.D.
degree in 1901 and also a degree of Doctor
of Public Health in 1922. While at the Uni-
versity, he had the distinction of being
elected to membership in Phi Beta Kappa,
to Sigma Xi, and to Alpha Mu Pi Omega
(Medical). His medical internship was at
the Presbyterian Hospital of Philadelphia.

1 Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

2 Mr. Cornell is the brother of Walter S. Cornell,
M.D. His address is 5939 Drexel Road, Philadelphia,
Pennsylvania 19131.

Following his internship, he became a
Lecturer in Anatomy and later in Hygiene
at the University of Pennsylvania, and at
the same time assisted on a part time basis
as a school inspector in the city's Health
Department. In 1912, the school medical
work was transferred from the Health De-
partment to a new department in the office
of the Board of Education, and he was
chosen as its first Director of Medical Serv-
ices, an office which he held for 31 years.
When, in 1943, he reached retirement age,
he quit his salaried position but not his
work for the School Board. He continued
on a volunteer basis as the Director of the
School Health Fund, a charitable fund
raised by private contributions in which
teachers and pupils in the schools partici-
pated and to which Dr. Cornell's wife and
some personal friends contributed very
generously. The money which was raised
was used to furnish to underprivileged chil-
dren certain medical and dental services
which cotdd not be allowed from the city's
budget. Dr. Cornell continued in this work
up to the time of his last illness.

In addition to his teaching at the Uni-
versity of Pennsylvania which continued
until 1956, he also served as Assistant Pro-
fessor of Public Health and Preventive
Medicine at Temple University for several
years.

He held the offices of President of the
Philadelphia County Medical Society,
Chairman of the Public Health Section of
The College of Physicians of Philadelphia,
Chairman of the Section on Child Hygiene
of the American Public Health Association,
Chairman of the Medical Advisory Com-
mittee of the Philadelphia Chapter of the
National Foundation for Infantile Paralysis,
and Editor of the Diabetic Digest of the

257

258

HERBERT W. CORNELL

Delaware Valley Diabetic Association. He
also was a member of the American School
Health Association, from which he received
the Home Award, and of the Philadelphia
Council of Boy Scouts, from which he re-
ceived the Silver Beaver Award. He was a
member of the Philadelphia Union League
and was a Mason.

During World War I, he served as a
Colonel in the Army Medical Reserve
Corps, and up to the time of his death he
had membership in Benjamin Franklin
Post #405 of the American Legion.

Aside from his medical work, Dr. Cornell
was greatly interested in two recreational
charities for children, the College Settle-
ment Farm Camp near Horsham, Pa., and,

adjacent to it, the Kuhn Day Camp. The
latter was founded and endowed by his wife
in memory of her parents, Henry J. and
Willemina B. Kuhn. These two children's
camps operate together, and, although they
are organized as separate corporations, they
have unified control with the same people
serving as Trustees in both organizations,
and this naturally included Dr. and Mrs.
Cornell up to tbe time of their deaths. They
were married in 1922, Mrs. Cornell dying
after a long illness in 1965.

Dr. Cornell was a member since boyhood
of the Girard-Welsh Presbyterian Church,
and also, for his last decade, of the Over-
brook Presbyterian Church. His residence
was at 5939 Drexel Road, Overbrook.

Memoir of Lewis Kraeer Ferguson
1897-1968*

By PAUL NEMIR, JR., M.D.

ON Sunday, April 7, 1968, Dr. Lewis
Kraeer Ferguson, master surgeon,
distinguished teacher and author,
and Fellow of The College of Physicians
for 33 years, quietly passed away, after a
protracted illness.

Kraeer Ferguson was born in Allegheny,
Pennsylvania, on April 29, 1897, the fourth
son of Huber and Carolyn Kraeer Fergu-
son. His father served as a minister of the
United Presbyterian Church in Washing-
ton, Pennsylvania, for many years.

Kraeer attended Xenia High School in
Ohio and in 1914 was admitted to West-
minster College in New Wilmington, Penn-
sylvania, where he made an outstanding
record. It was during his stay at Westminster
that he decided to go into medicine, rather
than to follow in the footsteps of his father
and grandfather in the ministry.

During his last year at Westminster, he
made application to the University of Penn-
sylvania School of Medicine, and it is prob-
able that at this time the first complication
in his well-ordered life occurred. Early in
December of 1917, he and 11 other mem-
bers of the senior class at Westminster were
called to the colors, and he was soon sent to
France. His application was considered at
Pennsylvania and early in 1919 Dean
William Pepper wrote to the authorities at
Westminster College, stating that there had
been no mention in the application that
young Ferguson had received credit for the
course in organic chemistry. He pointed out
that organic chemistry was required for
admission to the University of Pennsyl-

• Read before The College of Physicians of Phil-
adelphia, 14 May 1969. Prepared and published at
the request of the Council of The College of Physi-
cians of Philadelphia.

vania. Kraeer had apparently much im-
pressed his teachers, for Professor Charles
Freeman answered Dean Pepper's inquiry,
as follows: "He did not complete the course,
owing to the fact that he was called to the
service of his country during the school
year, but while he was in the class he was a
most efficient and satisfactory student, and
was granted the A.B. degree in absentia by
the faculty at the commencement of 1918."
He was admitted to the University of Penn-
sylvania.

Young Ferguson began his studies at
Pennsylvania in 1919 and received his medi-
cal degree in 1923. He continued his out-
standing academic record and was elected to
Alpha Omega Alpha. He served his intern-
ship at the Hospital of the University of
Pennsylvania for two years. Thereafter, as
recipient of the Agnew Fellowship in Sur-
gery, he completed his surgical residency
training in 1928 as the first resident in a
formal training program at the University
of Pennsylvania.

He then spent one year in Germany at
the University of Frankfurt and in 1929
returned to Philadelphia. He was appointed
Instructor in Surgery at the University of
Pennsylvania and Chief of the Surgical
Outpatient Clinic at the University Hospi-
tal. In 1938 he was promoted to Assistant
Professor and also began to serve as one of
the Chiefs of Surgery at the Philadelphia
General Hospital.

In 1942 he entered the Naval Medical
Corps and went with the University of
Pennsylvania Naval Medical Unit, orga-
nized in 1935 by Dr. Richard A. Kern, to
relieve the regular naval medical staff on
the USS Solace. The Solace, a superbly
equipped new hospital ship, was then going

259

260

PAUL NEMIR, JR.

into service in the Pacific Theatre. As the
Chief of Surgery, he helped compile a rec-
ord low mortality rate from battle casu-
alties. Of 4,039 patients treated on the ship,
only 12 died.

Upon his return to the United States, he
was appointed Chief of Surgery at the
United States Naval Hospital at St. Albans,
New York. He was discharged in October,
1945, with the rank of Captain.

He returned to Philadelphia and was
appointed Clinical Professor of Surgery at
the University of Pennsylvania. The fol-
lowing year he was appointed Professor of
Surgery in the Graduate School of Medi-
cine. Also, in 1946, he was appointed Pro-
fessor and Chairman of the Department of
Surgery at the Woman's Medical College of
Pennsylvania, a position which he held
until 1959. In 1959, he succeeded Dr. Her-
bert Reid Hawthorne as Chairman of the
Department of Surgery in the Graduate
School of Medicine and Chief of Surgery at
the Graduate Hospital. He served in this
capacity until his retirement in 1962.

These are the facts. They tell a lot. There
is more, however, of a lasting nature, which
should be told. What were those qualities
in Kraeer Ferguson that allowed him to
attain such eminence and which were im-
pressed on the young people whom he
taught and trained. The attributes are not
difficult to pinpoint in this instance. They
were an excellent intellect, hard work in
his chosen endeavor and complete dedica-
tion to it, and an absolutely thorough and
meticulous approach to every activity in
which he was engaged.

There were many stages in his life where
these attributes were clearly demonstrated.
Some were early shown and early recog-
nized. In the correspondence of 1919 be-
tween Huber Ferguson and the Pennsyl-
vania School of Medicine, the father wrote
of the work which his son was doing in
Europe during the time of his enlistment
and immediately after the Armistice. A short
paragraph from one of these letters is re-

vealing: "In addition to the work which the
registrar has certified, I can testify that he
has been in attendance at the University of
Marseilles from March 14 to June 14, and
has devoted his time to chemistry (lectures
and laboratory work) and to French. Of
course, I know nothing of the kind of work
he did, but I would expect it to be
thorough." It was characteristic that Kraeer
would utilize his time to the fullest advan-
tage on cessation of hostilities.

During the summer of his second year in
medical school, he applied for a position as
an extern at the Connecticut State Hos-
pital in Middletown, Connecticut. A letter
from the dean to the superintendent of that
institution stated as follows: "I take great
pleasure in recommending him for your
kindly consideration. Mr. Ferguson is an
exceptionally good student, one of the best
men in his class, and is everything that
could be desired, and I feel that you will be
very well pleased with him, should you give
him the appointment which he seeks."

These same attributes were again demon-
strated during the one year he spent in
Germany at the University of Frankfurt,
and it was on the basis of that experience
that he translated the two-volume book,
Operative Gynecology, by Dr. H. B. Pehan
and Dr. J. Amreich into English.

These same attributes were demonstrated
during the time that he was the Chief of
the Outpatient Clinic when, in addition to
a multitude of other duties, he began the
work on two books. One of these, The Sur-
gery of the Ambulatory Patient, was pub-
lished in 1942 and has gone through a num-
ber of revisions. It is a standard reference
work in the field. The other, Surgical
Nursing, is now in the 11th edition. The
earlier editions were published with Dr.
Eldridge Eliason, with whom Dr. Ferguson
received much of his early surgical training.

They were demonstrated so well during
the outstanding record on the USS Solace.
A colleague, writing about this experience
in later years, stated: "Even Fergy could not

MEMOIR OF LEWIS KRAEER FERGUSON

'21,1

complain about not having enough sur-
gery to do."

And, finally, they were demonstrated re-
peatedly in his teaching and demonstra-
tions to students and house oflicers. He was
precise and meticulous in his dissections
and had that rare quality of being able to
expound succinctly even when operating
under the most stressful circumstances.

Several months prior to his retirement,
Dr. Ferguson was suddenly incapacitated
with a cerebral vascular accident. While
there was gradual recovery, he never re-
gained full use of his left hand and he,
therefore, retired from active practice.

Despite this severe handicap, he did, how-
ever, continue to be active in teaching and
in his writing. It was during this period that
he spent the major portion of his time on
the third book, soon to be published, en-
titled, Explain It to Me, Doctor. He had
long felt that doctors did not spend enough
time explaining an illness to a patient, or
what surgery was being done, or what was
to be accomplished by surgery, and he
hoped that this book would help fill the
need.

In addition to his books, Dr. Ferguson
was also author or co-author of more than
150 articles published in medical journals.
These were based on observations from his
wide clinical experience and dealt with a
diversity of topics, among them, carcinoma
of the stomach, gastrointestinal hemor-
rhage, gastric resection, regional enteritis
and ulcerative colitis.

Dr. Ferguson was a member of many
medical organizations, including the Ameri-
can Medical Association, Philadelphia
Academy of Surgery, American Gastroen-

terological Association, American College
of Surgeons, American Surgical Association,
Bockus International Society for Gastroen-
terology, American Society for Experimen-
tal Pathology, Sigma XI, Federated Ameri-
can Society for Experimental Biology, Pan
Pacific Surgical Association, International
Surgical Group, Soci^td Internationale de
Chirurgie, Sydenham Coterie, and the Sur-
geons Club. He served as an officer in a
number of these organizations.

He was named Honorary Professor at
the University of Santo Domingo in the
Dominican Republic. In 1960, he received
the Alumni Achievement Award from his
alma mater, Westminster College, for dis-
tinguished accomplishment. In his honor,
Woman's Medical College of Pennsylvania
has established the L. K. Ferguson Visiting
Professorship to bring guest professors to
the college.

Because of his ability and interest in
medical writing, the University of Pennsyl-
vania School of Medicine is establishing a
Memorial Prize for young physicians to
attain greater competence in medical writ-
ing.

Surviving are his wife, the former Ruth
Griswold; three daughters, Mrs. T. Leonard
Shephard, Mrs. Karl Meyers and Mrs.
Gerald McConomy; two step-daughters,
Mrs. Richard G. Ulrich and Ann Hender-
son; three brothers, Robert G., Paul and
Dr. James; three sisters, Mrs. William
Hoover, Mrs. William Thomas and Mrs.
Helen Eckerson, and nine grandchildren.

Dr. Ferguson will be missed, but through
his Visiting Professorship, Memorial Prize,
his books and, most especially, his trainees,
he will be long remembered.

Memoir of Harrison Fitzgerald Flippin

1906-1968*

By CHARLES A. W. UHLE, M.D.

HARRISON Fitzgerald Flippin lived
a life of extraordinary dimensions.
His is the story of excellent per-
formance and outstanding achievement. A
native Virginian, he spent his early youth
and student years in the Cavalier country.
In the latter half of his life, Philadelphia
and Douglassville, Pennsylvania, claimed
him as their distinguished citizen.

He was born in Charlottesville, Virginia,
on October 26, 1906. Of fine patrician stock,
and, with an upbringing of the highest
spiritual quality, his character and bearing
were moulded in early life to make him a
leader amongst men. He possessed a keen
intellect. He was original and independent
in thought. His industrious application to
whatever the project yielded tremendous
results. His warm personality and genial
smile, combined with a keen sense of
humor, won him many friends. With the
numerous honors that were bestowed upon
him, he remained a simple, God-fearing
man whose heart knew compassion and
humility. The fine coordination between
body and mind carried him to the pinnacle
of athletic prowess. The accolade of the
University of Virginia's finest athlete ever
to graduate from this venerable institution
is still to be challenged. His father, Dr.
James Carroll Flippin, an internist and
Dean of the University of Virginia's Medi-
cal School, undoubtedly was a potent stimu-
lant to his son's embracing the study of
medicine.

Harry, and/or Flip, as he was known to
his family and many friends, attended the
Episcopal High School in Alexandria, Vir-

* Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

ginia. Here he developed into a superior
student and stellar athlete. He was profi-
cient in a multiplicity of sports and left an
enviable record in track when he was gra-
duated in 1926. Flip remained a loyal
alumnus and always maintained a great
interest in his many friends amongst the
faculty and student body. Later in life came
election to the Board of Trustees and mem-
bership on various important policy-making
committees. The crowning glory of his
student days was the recognition of his past
triumphs in the dedication on May 13, 1967,
of the Harrison Fitzgerald Flippin Field
House on the Alexandria campus, a gift of
his numerous friends and patients.

He was graduated from the University of
Virginia in 1929, establishing an enviable
record in scholastics and sports. A few of
the honors bestowed were election to Phi
Beta Kappa, the presidency of his senior
class, and membership in O.D.K., the na-
tional leadership fraternity.

He had played first base on the Episcopal
High School team and was offered in 1926
a contract in pro baseball by the late Clark
Griffith, owner of the Washington Senators.
This was not accepted because of his ambi-
tion to become a doctor. In college the pur-
suit of his premedical studies came first, his
spare time being allotted to making records
in track and football. The year 1927
claimed him as National Pentathlon Cham-
pion, a grueling test: the 220 yard dash, the
mile, the broad jump, discus and javelin. In
1929 he held the world indoor record for
the 60 yard high hurdles and tied the mark
for the 50 yard low hurdles. Flip was never
defeated in closed competition, either at the
High School or the University. In the
spring of 1929, he outdistanced a notable

262

MEMOIR OF HARRISON FITZGERALD FLIPPIN

263

group of competitors to win the 120 yard
high hurdles event in the Penn Relays at
Franklin Field. In 1927 he was a member
of the All-American Track Team, and in
1928 he was named End on the All
Southern Conference Football Team.

Harry was graduated from the University
of Virginia Medical School in 1933 and was
president of its senior class. Following the
scholarship as well as the athletic tradition,
he was elected to A.O.A.

Alter serving his internship at the Hospi-
tal of the University of Pennsylvania, he be-
came its Resident, then its Chief Medical
Resident, and finally the Edward Bok Fel-
low in Medicine.

From 1937 to 1965, he practiced internal
medicine in Philadelphia, finding time dur-
ing these years to produce 242 publications
and 2 books, Medical State Board Questions
and Answers and Antimicrobial Therapy.
He held the rank of Clinical Professor of
Medicine at the University of Pennsylvania.
He was a popular teacher and much in
demand as a speaker.

For many years he was Visiting Physician
to the Philadelphia General Hospital and
at the time of his death held the rank of
Active Honorary Consultant. In 1951 he
was appointed as an Associate to the Medi-
cal Staff of the Lankenau Hospital. His
pioneer work in chemotherapy brought him
world renown. His clinical and research
work in the field of bacteriology and micro-
bial therapy led to the modern concept of
infectious disease treatment and manage-
ment. He was among the first to show that
the sulphonamides could reduce the mor-
tality of pneumonia by fifty percent.

Harry was a Diplomate of the American
Board of Internal Medicine and a Fellow of
the American College of Physicians; he
belonged to a legion of medical societies.
Many academic honors were accorded him.
At one time or another he served on the
boards of numerous medical and non-medi-
cal institutions.

During World War II, his war effort was

directed to the Office of Scientific Research
and Development. Also in the later years
of his life he was appointed a member of
the Board of Health of the City of Phila-
delphia.

He was a staunch Episcopalian and a
member of the vestry of his neighborhood
church.

In 1937, Harry was married to Edith
Quier of Reading, Pennsylvania, one of
America's outstanding women golfers, and
amusingly enough one whom he was never
able to defeat on the links in any type of
competition. To this union were born three
children, James Carroll, William Seyfert
and Lucy Lee. He loved his family deeply
and often spoke of them. Their talents and
many accomplishments were a source of
pride to him.

One of his closest friends, W. Thornton
("Pete") Martin has reported the following
quotation from a conversation with Harry:
"During every man's life, many things
happen to him which he owes to other
people, to other institutions. In my own
life, I owe more to the Episcopal High
School than I can ever possibly repay. I not
only got an academic training there; I was
also able to take part in athletics. The com-
petitive instinct I absorbed there helped me
all through life. In later years, when I was
running for my patients, as a physician
against the Grim Reaper with the bony
fingers and scythe, I'm glad to say I some-
times came in first."

During his long and tragic illness, he dis-
played the tremendous faith, the fortitude,
the stoicism, the personal heroism which
placed him above the common herd. This
same Grim Reaper, of whom he had so
often spoken, took His toll on November
21, 1968.

Harry loved life and cherished the bonds
of friendship of the many people he knew.
His was the faculty of treating the serious
in a light vein and of making his friends
laugh with his wit and facetious remarks.
As the final curtain was coming down,

264

CHARLES A. W. UHLE

Harry referred to his impending burial in
old St. Gabriel's Churchyard in Douglass-
ville as going to join his old friends, the
Indians and Revolutionary War heroes who
had been buried in its historic and hal-
lowed ground.

Knowing him well, and keenly apprecia-
tive of his friendship through these many

years, sharing in a professional relationship
that was never marred by an argument or
dispute, and having the privilege to ad-
minister to him in his illness, I can say
without equivocation, "Here was a man,
a man of extraordinary stature. He was as
great a physician as he was an athlete."

^ -

Memoir of Abraham Mapow
1907— 1969*

By FREDERICK HARBERT, M.D.

ABRAHAM Mapow, M.D., Instructor
/-\ in Otolaryngology at the Jefferson
Medical College of Philadelphia,
died suddenly on May 4, 1969.

He was graduated from Temple Univer-
sity with a B.A. degree in 1929 and an M.D.
degree in 1933. He interned at the Albert
Einstein Hospital in 1933-4. He attended
the Graduate School of the University of
Pennsylvania in Otolaryngology in 1940
and was certified by the American Board of
Otolaryngology in 1949.

He was a member of the Philadelphia
Laryngological Society, The College of
Physicians of Philadelphia and the Ameri-
can Academy of Ophthalmology and Oto-
laryngology.

For twenty years he taught in the Gra-
duate School of the University of Penn-
sylvania and Philadelphia General Hospi-

• Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

tal, volunteering many hours per week in
these activities. In the last ten years, he was
equally faithful in teaching medical stu-
dents and residents at the Thomas Jefferson
University Hospital and the Jefferson Medi-
cal College affiliated hospitals, Philadelphia
General Hospital and the Veterans Admin-
istration Hospital at Wilmington.

In addition to his private practice, he
gave extensive service to the Police and
Fire Departments of Philadelphia and
served on the staffs of Roxborough Memo-
rial Hospital and Oxford Hospital. He was
a devoted member of the B'nai Abraham
Synagogue. His hobbies included a collec-
tion of classical records.

To his friends and colleagues, he will be
remembered as a family man, completely
devoted to his wife, Claire, and children,
Sherry, Mark and Larry. His youngest child,
Larry, is a Ursinus College junior and pre-
medical student. To have his son follow his
profession would be Abe's greatest pleasure.

265

Memoir of Ford A. Miller
1895-1968*

By JOHN D. CORBIT, JR., M.D.

FORD A. Miller, M.D. was born in
Easton, Pennsylvania, on January 3,
1895, and was graduated from La-
fayette College in 1917. He was a member
of Phi Beta Kappa and received his medical
degree from the University of Pennsylvania
in 1921. Starting as intern from 1921-3,
Dr. Miller was to devote all of his life to the
Pirsln tcrian Hospital. As Chiel Resident
during 1923 and 1924, he began his active
interest in the Alumni Association for
which he provided support and leadership
until his death.

Dr. Miller was licensed in the Common-
wealth of Pennsylvania in 1923. He became
an Instructor in the Graduate School of
Medicine of the University of Pennsylvania
in 1924 and continued teaching there until
he resigned as Assistant Professor of Obstet-
rics and Gynecology in 1910. During these
years, he was active on the staffs of botli
Presbyterian and Graduate Hospitals.

* Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

Having been certified by the American
Board of Obstetrics and Gynecology in 1935,
he became Chief in the Department of Ob-
stetrics and Gynecology at the Presbyterian
Hospital in 1939 and continued in this re-
sponsibility until 1960. Dr. Miller, at vari-
ous times, had been on the staffs of the Gra-
duate, Philadelphia Lying-in, Woman's and
Methodist Hospitals. From 1940 to 1960, he
devoted his full time and energy to im-
proving the service at Presbyterian.

He was an active participant in the affairs
of the Philadelphia County Medical Society
and the Philadelphia Obstetrical Society.
He was elected to The College of Physicians
of Philadelphia on October 2, 1935. Dr.
Miller was much too devoted to his patients
to be able to enjoy fully his membership in
the Philadelphia Country Club, the Union
League and the Masons.

At the age of 73 and after 47 years of
practice, Dr. Miller died in the Presbyterian
Hospital on December 5, 1968. Our com-
munity has lost a dedicated clinician, a
devoted teacher and a loyal friend.

266

Memoir of Gerald H. J. Pearson
1893- 1969*

By BERNARD J. ALPERS, M.D.

DR. Gerald Hamilton Jeffery Pearson
was born in Key West, Florida, on
September 21, 1893, and died in
Philadelphia on July 2, 1969. He was a
graduate of the University of Western On-
tario and of the University of Western
Ontario Medical School. After eight years
of general practice in Ottawa, Canada, he
entered the Graduate School of Medicine
in the University of Pennsylvania, where
he was a Commonwealth Fellow in Neuro-
psychiatry from 1925 to 1928, receiving the
degree of Doctor of Science in Medicine
(Sc. D., Med.). He entered the practice of
child psychiatry in Philadelphia, which
for the rest of his very productive life was
the source of his professional activities. He
became associated with Temple Univer-
sity, where he served as Associate Professor
of Child Psychiatry from 1940 to 1948.
For many years he was Dean and Director
of child analytical training of the Institute
of the Philadelphia Association for Psycho-
analysis, where he exerted a wide influence
as teacher and as preceptor. He retired as
Dean in 1959 at age 65. He was Professor
of Psychiatry at Hahnemann Medical
College and from 1962 to the time of his
death he served as Professor Emeritus.

He was a prolific and influential writer,
and he was the author of many volumes
and articles in the field of child analysis.
His books included Emotional Disorders
of Children, Adolescence and the Conflict
of Generations, and Psychoanalysis in the
Education of Children. He edited A Hand-
book of Child Psychoanalysis, and he was
co-author of Emotional Problems of Living

* Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

and Common Neuroses of Children and
Adults.

He was a member of the American Psy-
choanalytical Society, the American Ortho-
psychiatric Society, the American Group
Therapy Association, the American Society
of Psychosomatic Medicine, the American
Medical Association, the Philadelphia
Pediatric Society, the Philadelphia Psychi-
atric Association and the Philadelphia
Neurological Society.

During World War I, he was a Captain
in the Canadian Army, and in World War
II he served as consultant for the U. S.
Women's Army Corps.

He is survived by his wife, the former
Mary Agnes McKenzie; two daughters,
Mrs. Francis P. Bucher and Mrs. Lesley
A. Fridenberg; a son, Lieutenant Com-
mander (USN) George R.; and by a sister
and four grandchildren.

Child psychiatry is now a respected and
accepted branch of general psychiatry.
Hence it is difficult to realize how great
were Dr. Pearson's contributions and how
important was his influence in a day when
not only was child psychiatry not recog-
nized as a specialty, but in which psycho-
analysis was looked upon almost with
derision. During his years as a Common-
wealth Fellow, he fought vigorously for
the privilege of tailoring his studies to
suit his needs and thus established a prin-
ciple of graduate study from which those
who followed him derived great benefit.
His struggle developed out of a training
environment which was strongly oriented
toward an organic philosophy, and while
he accepted this feature of his education
he established also his right to pursue his
psychiatric interests, a not inconsiderable

267

268

BERNARD J. ALPERS

feat in a department which was heavily
weighted in favor of organic neurology.
His training and his background in gen-
eral practice, as well as his intellectual
perspective, led him to recognize the im-
portance of structure in emotional prob-
lems. To the practicing physician this is
now an accepted concept, but for an ana-
lyst this was a revolutionary approach, and
he was one of the pioneers of the psycho-
somatic concept of psychiatric disorders.
He remained conscious of both physical
and emotional factors throughout his
career.

After the completion of his graduate
studies, he became convinced that the
symbolizations of child thinking and play
could be understood best against a back-
ground of psychoanalysis. After arranging
for his own analysis, he came to apply
analytical methods to the treatment of
problems of abnormal behavior of chil-
dren. The courage which this entailed
must be understood against the back-
ground of Philadelphia psychiatry at the
time in which his decision was made. Not
only was psychiatry still in the Kraepelin-
ian stage; it was also openly antagonistic
to Freud in particular and to psychoanaly-
sis in general. His convictions brought
him into conflict with the treatment
philosophy of the Philadelphia Child
Guidance Clinic of which he was then a
staff member. Because the two opposing
concepts could not be reconciled, he left
the clinic in order to establish one of his
own in Temple University. Here and in
other departments where he worked later
he established his school of child psychia-
try where he trained many men who have
continued his tradition. His viewpoint is
reflected in his books, which he wrote for
the general public and for those in medi-
cine who were not psychoanalysts. His
book on Adolescence was a clear descrip-
tion of the problems of the growing man
and woman, and anticipated by several

years the present concern about the gen-
eration gap. The Handbook of Child
Psychoanalysis was the first authoritative
book of its kind, the product of his own
school of thought.

He was a remarkably refreshing psychia-
trist, who could be best characterized as a
sensible psychoanalyst. He was never car-
ried away by slogans. Permissiveness and
discipline were not contradictory, particu-
larly self-discipline. His training program
in child analysis had as its basis a thorough
understanding of child development, both
physically and emotionally. It was one of
the major principles of his teaching that
this development was constantly changing
from childhood to adolescence and that
treatment methods needed adjustment to
the demands of growth and change. He
was no slave to a technique, despite the
fact that his life work was done in a branch
of medicine where this becomes easily
possible. He was well aware of the short-
comings of analysis and of determinism
as a philosophy; hence, his opinions were
well considered and remarkably broad in
their perspective. He was never one to
stretch facts or inferences, and behind all
his analytical learning was a soft heart and
great common sense. Though he was an
orthodox Freudian, he lacked the rigidity
of concept of many members of that
group, and he was even acquainted with
and interested in the organic neurological
problems of children. Some of his early
work had to do with the problem of
aphasia and the development of speech in
children. Their speech disorders con-
tinued to interest him throughout his pro-
fessional life.

He was a kind, gentle and understand-
ing man, and it was these basic qualities
which endeared him to his friends and
made him such a great psychiatrist. His
interests apart from medicine were broad.
He was raised in an environment which
provided him with a firm love of the Bible.

MEMOIR OF GERALD H. J. PEARSON

269

He loved poetry and was fond of quoting
it. His friends remember him for his
wisdom and tolerance and for his consid-
erate patience. Like Lord Acton, he was
able to judge character at its worst without
loss of faith in his fellow-man. There were

many among family, friends and patients
who looked to him for help. All who were
so fortunate as to be touched by his gentle
spirit were enriched and ennobled by the
experience.

Memoir of Stanley P. Reimann
1891^1968*

By TIMOTHY R. TALBOT, JR., M.D.

STANLEY P. Reimann was a man of
great energy, gifted imagination,
quickness of mind, persistence of pur-
pose, and much courage and conviction.
There is no doubt that he made a great
contribution to biological and medical re-
search and that he was one of the major
forces in bringing the word "cancer" out
of the darkness of fear and secrecy into the
light of scrutiny and study. He had a
bright personality and always left a vivid
impression on everyone he met.

I never knew Stanley Reimann until
after I had become his successor as Direc-
tor of The Institute for Cancer Research,
but in the succeeding decade I had the op-
portunity to know him and to learn at
first hand much of the history of the pre-
ceding 32 years in which he was so deeply
involved. I have had the additional advan-
tage of knowing many of the people with
whom he worked for many years and of
seeing the true nature of his philosphy as
it was expressed functionally through the
Institute. Stanley Reimann had no desire
whatever to retire when he did, so that his
friendly acceptance of me led to a unique
relationship and lent expression to his
largeness of spirit.

Numerous obituaries have already been
published to chronicle his formal accom-
plishments, awards and honors. These may
be summarized as follows:

Stanley Reimann was educated in his
native Philadelphia at Central High
School and at the University of Pennsyl-
vania, from which he received the degree
of Doctor of Medicine in 1913. He in-

* Read before The College of Physicians of Phila-
delphia, 14 May 1969. Prepared and published at
the request of the Council of The College of Physi-
cians of Philadelphia.

terned at The Lankenau Hospital in
Philadelphia, was a resident pathologist at
the Lakeside Hospital in Cleveland, and
was a Hanna Fellow in Experimental
Pathology at Western Reserve University.
Upon his return to Philadelphia, he was
named pathologist at The Lankenau
Hospital and soon became concerned
about the cancer problem.

The vision and ability of Dr. Reimann
to transmit his enthusiasm to others were
responsible for his most important con-
tribution to science and medicine, namely,
the founding in 1925 of The Lankenau
Hospital Research Institute for the study
of normal growth as well as cancer. His
first partner in the scientific aspects of this
project was Dr. Frederick S. Hammett, a
physiologic chemist. Both men viewed the
study of cancer as a fundamental problem
of growth and differentiation and felt
that a successful attack required the team
work of biologists and chemists.

By the second decade of its existence,
the Institute had attained world-wide
recognition due to the foresight and
energy of the Reimann-Hammett team.
Growth of the research organization con-
tinued steadily, and in 1945 The Institute
for Cancer Research was formed with Dr.
Reimann as Scientific Director. A few
years later the research staff moved into
greatly expanded quarters at the present
Fox Chase location. Again the principle of
conducting basic research in biology,
chemistry and physics and the conviction
that an understanding of the processes of
growth and development would ultimately
provide necessary knowledge for the con-
quest of cancer were uppermost in Dr.
Reimann's thinking and actions.

Dr. Reimann was a member of the

270

MEMOIR OF STA

Board of Directors of the American Asso-
ciation for Cancer Research from 1950 to
195:5 and was Vice President (1951-2) and
President (1952-3). He also served the As-
sociation capably as a member and often
as Chairman of its Committees on Invest-
ments, Finance, Program and Local Ar-
rangements and was a regular attendant at
the annual scientific meetings from 1931
! to 1966.

| Recognition from various sources came
to Dr. Rcimann during his 32 years as
Director and Scientific Director of the In-

i stitute. He was appointed Professor of

! Surgical Pathology in the Graduate School
of Medicine at the University of Penn-

i sylvania, Professor of Oncology at Hahne-

' mann Medical College, Chief of Clinical
Oncology at The Lankenau Hospital, and
consulting pathologist at the Jeanes and
The American Oncologic Hospitals. In

i 1937 he received the Ward-Burdick Medal
from the American Society of Clinical

; Pathologists in recognition of his contri-

, butions to the basic sciences, and in 1957
the Strittmatter Award of the Philadelphia

, County Medical Society was bestowed
upon him for his contribution to the art

, and science of medicine. Honorary doctor-
ate degrees were conferred upon him by
the Hahnemann Medical College (1945)

: and the Philadelphia College of Pharmacy

1 and Science (1950). Dr. Reimann held a
variety of important positions with the

. American Medical Association, the Phila-
delphia County and the Pennsylvania
State Medical Societies, the American and
Philadelphia College of Physicians, the

i American Society of Clinical Pathologists
(President 1946-7), and other national so-
cieties concerned with various aspects of
pathology. From 1948 to 1960, he served
on the Council on Scientific Assembly of

! the American Medical Association (Chair-
man 1958-60) and played a major role
in the organization of the general scientific
programs for the semiannual meetings of
this society. Dr. Reimann was active in
several social organizations, such as the

LEY P. REIMANN 271

Union League of Philadelphia and the
Pocono Lake Preserve, in addition to his
work with various musical organizations.

In 1957, having reached the age of re-
tirement, Dr. Rcimann was appointed Di-
rector Emeritus of The Institute for Can-
cer Research. He immediately accepted a
Fulbright lectureship and went to India to
deliver a series of lectures and to partici-
pate in tumor clinics of the type that he
had introduced many years earlier at The
Lankenau Hospital. In 1963, in collabora-
tion with Dr. Grace Medes, he wrote a
book entitled Normal Growth and Cancer
to add to his previous output of more than
100 medical and scientific papers on car-
cinogenesis, wound healing, chemother-
apy, cancer control, and care of the cancer
patient.

He is survived by his wife, Elsie Bein
Reimann, two daughters, Mrs. George
Nehrbas and Mrs. John W. Bodine, and
six grandchildren.

A portait of Dr. Reimann was com-
pleted and unveiled two months before
his death; it hangs in the lobby of the In-
stitute he founded and will remind the
staff and visitors of the dedication of this
pioneering and inspiring leader of the Re-
search Institute from 1925 to 1957.

The calendar of events that marked his
education, training, honors and activities
attest to the recognized quality of his
scholarship and abilities. To those who
knew him, however, it is the man himself
who needs to be recalled and retained in
memory as a standard.

At a time when the nation was in the
throes of economic depression, he man-
aged to keep alive an ideal and a vision
which later flourished and grew into sta-
ble and lasting form. His concept that
biological and biochemical research were
the necessary basis for an understanding
of cancer was quite new when he was in-
strumental in founding The Lankenau
Hospital Research Institute in 1925. This
Institute later became The Institute for

272

TIMOTHY R. TALBOT, JR.

Cancer Research in Fox Chase, Philadel-
phia.

Stanley Reimann had great charm — he
liked people and always had a bright and
cheerful contribution to give to those
whom he encountered. He was a kindly
physician and never lost his contact with
patients. He liked children and they liked
him. He liked to go trout fishing and loved
the woods and all of nature. He remained
a skilled musician until the end of his life
and played the piano and organ with
genuine gusto. He loved to exercise his
fluent knowledge of the German language
and could do so at just the right moment
in just the right way — usually at the ex-
pense of the unwary.

He was a man deeply involved with all
of life and culture, and he moved through

life with unbroken adherence to the exu-
berant exercise of his talents and convic-
tions. He influenced hundreds of people —
probably thousands — and almost single
handedly created a new institution. He left
his mark on the world and helped to im-
prove it in all of the diverse areas where
he worked and lived. Medical education,
medical research and cancer research were
all perceived in a perspective by Stanley
Reimann in a way that led to their ad-
vancement and in a way that remains valid
today. He was in some ways ahead of his
time, and in other ways, not of his time.

Let us hope that other men will appear
who are cast from a similar mold, and be
grateful that his talents were directed to-
ward such high purposes.

Memoir of Helena E. Riggs
1899-1968*

By RUSSELL S. BOLES, M.D.

D

R. HELENA E. Riggs was born in
Philadelphia on December 18, 1899.
She was educated in private schools
and then at Bryn Mawr College in 1917.
After two years at Bryn Mawr, she trans-
ferred to the University of Pennsylvania,
from which she was granted a Bachelor of
Arts degree in 1921.

She then attended the School of Medi-
cine of the University of Pennsylvania
from which she received her M.D. in 1925.
Following this, she served as an intern at
the Philadelphia General Hospital, a
privilege which was rarely accorded
women in those days. She followed her in-
ternship with a year of graduate study in
Pathology at the University of Pennsyl-
vania. From 1928 to 1932, she was asso-
ciated with Dr. William McConnell in
the clinical practice of neurology. Dr.
Riggs had always been keenly interested in
neuropathology, and, following the death
of Dr. McConnell, she became associated
with Dr. Nathaniel Winkleman, who at
that time was part-time neuropathologist
at the Philadelphia General Hospital.

It was only natural because of her ex-
raordinary talent that she should become
full-time Chief of the Neuropathology
Laboratory at the Philadelphia General
Hospital in 1935, a position which she
held continuously until her death on
October 7, 1968. It is appropriate to record
here that the Laboratory of Neuropathol-
ogy at the Philadelphia General Hospital
was the first such laboratory to be estab-
lished in this country. In 1948, Dr. Riggs
and Dr. Webb Haymaker were the first

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

two neuropathologists to receive certifica-
tion in Neuropathology by the American
Board of Pathology.

During the second World War, Dr.
Riggs served as a consultant for the U. S.
Navy and was included in a team of spe-
cialists who had the responsibility of de-
veloping neurologists in a six-week period.

Dr. Riggs was President of the Phila-
delphia Neurological Society in 1950, an
honor that previously had never been ac-
corded a woman in the history of that or-
ganization. She was appointed Assistant
Professor of Neuropathology at the Univer-
sity of Pennsylvania in 1950 and in 1960
was advanced to full professorship in her
specialty.

Dr. Riggs was a member of the following
scientific societies: American Association
for Research in Nervous and Mental Dis-
eases, American Neurologic Association,
American Academy of Neurology, Ameri-
can Association of Neuropathologists,
American Association for the Advance-
ment of Science, Society of Biological Psy-
chiatry, The College of Physicians of Phila-
delphia, Philadelphia Neurological Society.
The American Association of Neuropa-
thologists recently approved the placing of a
plaque in the Neuropathology Laboratory
of the Philadelphia General Hospital. The
plaque was suitably inscribed as follows:
"To the memory of Dr. Helena Riggs,
in recognition of her services to American
Neuropathology."

Dr. Riggs was intensely devoted to her
specialty which she greatly enriched by her
many major contributions to its literature,
especially in the field of cerebral-vascular
disease. It was my good fortune to co-au-
thor a number of papers with Dr. Riggs,

273

274

RUSSELL S. BOLES

chiefly on the neurogenic and circulatory
factors in the etiology of peptic ulcer and
on Wernicke's Disease. At the time of her
death, Dr. Riggs was engaged in writing a
book on myelinization of the infant brain.
This book was the product of seven years'
study on this subject in which she was as-
sisted by Dr. Lucy Rorke, who joined her
in 1961, as an NIH trainee. Dr. Rorke re-
mained with her as her assistant until the
time of her death. Ironically, Dr. Riggs'
publishers, the J. B. Lippincott Co., de-
cided to accept her manuscript for pub-
lication just a few hours after Dr. Riggs
had died. Fortunately, Dr. Rorke was able
to complete the work so that it will be
published in the very near future. Dr.
Riggs was a scholar of high intellectual
achievement and as a superb teacher de-
voted much of her time to sharing her
knowledge with her colleagues and the
students who were fortunate enough to
work with her.

Her major avocational interests centered
about her home with its extensive gardens.
These were exquisitely nurtured and pro-

vided a deep source of satisfaction and
pleasure to her. She was also a gourmet
cook, one of those rare seamstresses who
never used a sewing machine even for
making dresses, and a particularly accom-
plished knitter and needle-worker.

She had always enjoyed excellent health
so that her sudden death from a massive
coronary while on holiday with her family
in California was especially shocking.

On December 18, 1968, a memorial serv-
ice was held in the Medical Library of the
Philadelphia General Hospital in honor of
Dr. Riggs. Dr. Charles Rupp, nationally
prominent Philadelphia neurologist and
long-time friend and associate, delivered
a eulogy in her honor. One of her out-
standing pupils, Dr. John McGrath, world-
renowned neuropathologist, added a sec-
ond tribute to the memory of this great
lady.

Dr. Riggs' passing creates a great loss in
the field of neuropathology, and one can
only hope that her many co-workers will
maintain the high traditions for which she
was so well admired.

Memoir of Lennard L. Weber
1915-1969*

By S. LEON ISRAEL, M.D.

1ENNARD L. Weber was a product of
. Philadelphia. He was born here on
May 18, 1915, received a Bachelor of
Arts degree from the University of Pennsyl-
vania in 1937, and was graduated from the
Hahnemann Medical College in 1931. He
married his childhood sweetheart, Rose
Gussman, while a medical student. Follow-
ing an internship at the Mount Sinai Hos-
pital (now Daroff Division of the Albert
Einstein Medical Center), he entered upon
a 4-year stint of active military service. He
served in the Medical Corps of the United
States Army, supporting troops in many
areas of the South Pacific, was decorated
for gallantry, attained the rank of Major,
and returned at the conclusion of World
War II to be plagued for several years by
recurring bouts of malaria. He entered
the field of obstetrics and gynecology by
being a resident for three years (1948-50)
at the Mount Sinai Hospital. He began
his practice in that specialty during the
fall of 1950 and was certified by the Amer-
ican Board of Obstetrics and Gynecology
in 1952. Doctor Weber's growing practice
did not interfere with his desire to con-
tribute to medical education and to be an
active member of obstetric and gyneco-
logic organizations. His activities as a
1 teacher were pre-eminent, initially in the
I Graduate School of Medicine and later in
the School of Medicine, University of
Pennsylvania. Several weeks prior to his
death he had been promoted to the rank of
' Associate Professor of Obstetrics and
j Gynecology at the University of Pennsyl-
vania. His hospital duties, always executed

• Prepared and published at the request of the
Council of The College of Physicians of Phila-
delphia.

with an earnest sense of responsibility, in-
volved him with the Graduate Hospital of
the University of Pennsylvania, Pennsyl-
vania Hospital and the Einstein Medical
Center. He had positions of senior respon-
sibility in each of them.

Doctor Weber was known as a reliably
dependable committee member in all of
his organizational work. He was an active
member of local and state medical socie-
ties, the American Medical Association,
the American College of Surgeons, The
American College of Obstetricians and
Gynecologists, The College of Physicians
of Philadelphia, the American Association
of University Professors, and the American
Fertility Society. He was especially earnest
in his efforts to assist in the early growth
and development of the local District work
of The American College of Obstetri-
cians and Gynecologists, involving himself
in all sorts of educational programs in
Pennsylvania, Delaware, and New Jersey.
He never failed to respond to a call for
work in the Philadelphia Obstetrical
Society in which he was, at the time of his
death, the First Vice-President. One of his
most distinctive contributions to the medi-
cal scene of Philadelphia was his splendid
chairmanship of the Maternal Welfare
Committee of the County Medical Society
for many years. Most of the senior obstetri-
cians in Philadelphia will recall the prodi-
gious effort he expended in the interest of
that Committee. Doctor Weber was par-
ticularly interested in the welfare of the
pregnant woman and her product, an in-
terest that probably stemmed from his
many years of service to the Maternal
Welfare Committee. During the last 10
years of his life, he brought a particular

275

276

S. LEON ISRAEL

devotion to the study of fetology and en-
gaged himself in several basic research ac-
tivities in that most important subspe-
cialty. In this spirit, it was most natural
for him to be willing to assume (by relin-
quishing some of his private practice) the
duties of Medical Director of the Maternal
and Infant Care Program at Pennsylvania
Hospital, an activity that he not only en-
joyed but carried off most effectively.

Doctor Weber's enthusiasm for his
chosen specialty never wavered. He was an
earnestly involved figure at any meeting,
identified readily by his impeccable order
of dress, charming affability and handy
cigar. Although prematurely terminated,
Doctor Weber's life was filled with service
to his profession in many ways and one
which he enjoyed because of his variegated
concerns. In addition, for many years he
indulged his hobby in photography, dis-
playing a widely admired artistic ability
as well as matchless taste. He was capable
of enthusiasm regarding works of art,
theatre and modern literature. Despite all
such varied interests, Doctor Weber re-
mained a deeply religious person, one de-
voted to the tenets and principles of his

faith. It was, perhaps, the latter charac-
teristic that sustained his dear ones and
close friends during the hours he planned
his immediate future, involving not only
the coming marriage of his only daughter
but also what he knew would be a long
recovery period, as he faced the known
ordeal of a radical operation for an esoph-
ageal carcinoma on February 14, 1969. He
succumbed to pneumonia during the sec-
ond postoperative week.

Doctor Weber is survived by his wife,
Rose, of 30 years; a daughter, Nancy; and
a son-in-law, Stephen Machinton, who is a
medical student. They may draw solace, as
do his many friends and patients, from
Doctor Weber's faith in God as well as in
people. Our much-loved friend, a paragon
of many virtues, left us with our knowledge
of his awareness that he had a glowing set of
family relationships, that he had imparted
countless lasting gems of knowledge to hun-
dreds of students as well as residents, and
that he had contributed to the welfare of
thousands of women as well as to the health
of their unborn children. He will rest in
peace.

A Letter from the Benjamin Rush House

Committee

II The Honorable Raymond P. Shafer

Governor, Commonwealth of Pennsylvania
I lie Honorable Hugh Scott

U. S. Senate
I he Honorable Richard S. Schweiker

U. S. Senate
I he Honorable James H. J. Tate

Mayor, City of Philadelphia
1 he Honorable Joshua Eilberg

U. S. House of Representatives
I he Honorable John F. Byrne
I J Senate of Pennsylvania

Hal B. Jennings. Jr., Brigadier General

The Surgeon General, United States Army
Mary Brooks

Director-Designate, U. S. Mint
Gerald I). Dorman, M.D.

President, American Medical Association
Raymond W. Waggoner, M.D.

President, American Psychiatric Association
Robert F. Gohcen
President, Princeton University

Sponsoring

University of Pennsylvania

Dickinson College

Franklin and Marshall College

Pennsylvania Hospital

Rush Hospital

Philadelphia State Hospital
American Psychiatric Association

I he Philadelphia Psychiatric Societv
Pennsylvania Medical Society
The Philadelphia County Medical Society
The College of Physicians of Philadelphia
Pennsylvania Historical and Museum Commission
| Historical Society of Pennsylvania

Philadelphia Societv for the Preservation of Land-
marks

Order of the Founders and Patriots of America
Descendants of the Signers of the Declaration of

Independence
City Parks Association of Philadelphia

ary Patrons

Gaylord P. Harnwell

President, University of Pennsylvania
Hon. iid L. Rubendall

President, Dickinson College
Keith Spalding

President. Franklin and Marshall College
\l I o<l,| Cooke, Jr.

Chairman, Board of Managers, Pennsyhania Hos-
pital

Francis C. Wood, M.D.
President, The College of Physicians of Phila-
delphia
Carl Binger, M.D.
Lister Hill

K.n I Mcnningcr, M.D.

Benjamin Rush

Jonas Salk, M.D.

Leon Sullivan

Paul Dudley White, M.D.

Dwight Wilbur, M.D.

Organizations

The Colonial Philadelphia Historical Society
Germantown Historical Society
Historical Society of Frankford
Somerton Civic Association

Holmcsburg-Torresdale Historical and Art Society
Pennsylvania Prison Society
The Federation of Jewish Agencies
The American Legion (Philadelphia County Coun-
cil)

Benjamin Rush Middle School

I lie Philadelphia Convention and Tourist Bureau
General Society of Colonial Wars
The Philadelphia Foundation
Merck Sharp & Dohme
The Hoffmann-La Roche Foundation
Residents Association — The Institute of the Penn-

s\ Ivania Hospital
Mental Health Association of Southeastern Penn-
sylvania

ACxROUP of citizens in Philadelphia
has recently organized the Benjamin
Rush House Committee, which aims
to reassemble and restore the birthplace of
the famous patriot and Signer of the Dec-

laration oi Independence. Many distin-
guished Americans have offered to serve as
Honorary Patrons. The Benjamin Rush
House Committee invites you to contribute
toward this effort.

277

"Who knows but it may be reserved for America to furnish the world from
her productions, with cures for some of those diseases which now elude the
power of medicine?"

Medical Inquiries and Observations, 1789

Benjamin Rush (1745-1813). Attributed to Benjamin West, this portrait hangs in The Col-
lege of Physicians of Philadelphia.

278

Id N | \MI\ Kl SH HOI SI COMMITTEI LET! I K

279

I ci us acquaint yon more lnll\ with
Benjamin Rush and with out project.

Doctor Benjamin Rush, the Eoremosi
physician ol the young American Repub-
lic, was in .1 modest stone farmhouse
in Byberry Township, now a section ol
Northeast Philadelphia. After graduation
from Princeton ,ii age II. In- obtained his
medical diploma at the University ol Edin-
burgh and began a lifetime ol medical
pi ac ( ic e in Philadelphia.

Rush's medical accomplishments alone
merit him a permanent place among the
giants of American medic inc. lie became
the first Professor of Chemistry at the Na-
tion's Inst medical school, the University
of Pennsylvania, and wrote the first book
on ehctnistiv in America, lie set ved as
physician to Pennsylvania Hospital lot
thirty years and became the hero ol the
yellow fevet epidemics ol die I790's. Be-
cause he published the hist book on men-
tal illness in America (1812), he is known
as the "Father of American Psychiatry,"
and his profile is in the seal of the Ameri-
can Psychiatric Association. He is likewise
hailed as "patron saint'' by obstetricians,
pediatric i. ins. veterinarians and tubercu-
losis specialists, as well as by those in
military medicine. He was 1 1 i c - most es-
teemed medical te.u hei of 1 St h Century
America and the first American ph\sician
to achieve an international reputation.

Rush was one ol the original twelve
founding Senior Fellows of The College of
Physicians of Philadelphia, lie was a mem-
ber of the Commit tee on Publication and
assumed the task, with William Shippen,
|r., and Samue l P. Giilhiis. ol preparing a
preface for the first issue of the Transac-
tions & Studies.

Benjamin Rush was far more than a
physician. Friend of Adams, Jefferson,
Franklin and Washington, he stands
among the greatest patriots of Revolu-
tionary times. He was a member ol the
Continental Congress in 177(i and a Signer
ol the Declaration ol Independence. He
gave the name Common Sense to Tom

P. line's fiery pamphlet He became Physi-
cian General in the Continental Aims.
Washington relied on his advice prior to
the Battles ol I teuton and Prince ton. In
more peaceful time s. Rush became I reas-
urer of the United Stales Mint.

The significance of Rush foi us today,
however, rests in his sociological contribu-
tions. With Benjamin Franklin, Rush
founded the first organization (1771) in
America for the abolition ol slavery. He
staunchly supported the Ereedom, educa
tion and religious instruction of black
Americans. He promoted public schools
and was also a founder of Dickinson Col-
lege as well as a founding trustee of
Franklin and Mat shall Colle ge . He sup-
ported the rehabilitation and reform ol
criminals, as well as the abolition of cruel
punishment and the- death penalty. He
advocated establishments for the cure ol
alcoholism. He promoted a dispensary lot
the medical relief of the pool .

In the light ol such ae c omplislinients,
you cm well understand our wish to pre-
serve Rush's birthplace as symbolic ol
ideals and goals for which we strive today.
The Rush House is the only birthplace ol
a Signer ol the Declaialion ol I ndepend
ence which we still have in Philadelphia,
where the Declaration was written and
proclaimed. The house was built in 1690
by John Rush, great-grandfathei ol Ben-
jamin, who fought under Cromwell and
who arrived in Pennsylvania in 1683. The
local neighborhood has gu n interest in its
pi eset \ ation, as evidenced l>\ the number of
local organizations serving as sponsors.

Let me now acquaint you with our
progress l<> date. Main citizens and organi-
zations, local and national, have formed
the' Benjamin Rush House Committee,
which is now proceeding to incorporate.
The stone and woodwork of the Rush
House have been transferred from its oris:-
i n.i I location (now a housing development)
to the grounds of the Philadelphia State
Hospital, where they can be carefully pro-
tected until the reassembling can begin.

280

BENJAMIN RUSH HOUSE COMMITTEE LETTER

The Commonwealth ol Pennsylvania has
given permission foi reconstruction ol 1 1 1 c
house on slate piopcm on a prominent
sile alom; I S. Route 1, where it will he
the lit. si hisioii( siiiHiure which the visitor
to Philadelphia will see on entering our
historic city by way of this busy highway.
Philadelphia Slate Hospital has indicated
that the house will Ire maintained in per-
peluit) as one ol the hospital buildings.
We hope that the linal result will resem-
ble Washington's Headquarters at Valley
Forge, a similar reconstruction project.

We are now ready to launch a nation-
wide fund-raising campaign for a goal of
$150,000. A generous initial contribution
of $5,000 has been made by the Philadel-
phia Foundation and sizable grants have
been received from Merck Sharp Sc Dohme
and I hillniann-LaRoche Foundation.

Tax-deductible donations may be made
to The Historical Foundation ol Pennsyl-
vania and mailed to Robert E. [ones,
M.I). Ch airman, benjamin Rush House
Committee, III \oilh 19th Slieet, Phila-
delphia. Pennsylvania 19139.

We hope you will support this worth-
while endeavor.
Sincerely yours,

The Benjamin Rush House Committee
Robert Frwin Jones, M.D.

Chairman
Daniel Blain, M.D.

Vice Chairman
Margaret M. Fluddleston

Secretary
Townscnd Munson

Treasurer
Harold Rosenthal

Counsel

To: The Benjamin Rush House Committee

c/o Robert E. Jones, M.D.

1 1 1 North 49th Street

Philadelphia, Pennsylvania 19139

My tax-deductible contribution of $ , payable

to the Historical Foundation of Pennsylvania, is enclosed.

Name

Address.

TRANSACTIONS 9f STUDIES

of

The College of Physicians of Philadelphia

Volume 37
(Fourth Series)

Number 4
(April 1970)

The Philadelphia Neurosurgical Society 1

By FREDI.RICK MURTAGH, Jr., m.d., f.a.c.s. 2

I

WELCOM1 this oppoi utility to speak
about the Philadelphia Neurosurgical
Society. Ii is rather startling, however,
to discovei suddenly thai something with
which one has been so iloseh associated
has become ol historical significance.

Physicians are the most gregarious peo-
ple. They constantly need the association
of other physicians for exchange ol ideas
to feed theii intellectual appetites and as
soil in which to seed the products ol then
own fertile minds. The development of
American medicine can be easily traced
tin 'ough the archives ol an astounding
number of medical organizations and
societies thai have been formed and have
existed since the first physician set foot in
America. Every society is formed as a re-
sponse for a need to communicate, and it
will flourish so long as thai need exists.
If the basic need becomes submerged in
the academic and social progress of medi-
cine, the organization may find a new pur-
pose for its existence, merge with another
society, or disband. In this manner, most
organizations have survived in one form

'Section on Medical History, The College of
Physicians of Philadelphia, 18 November 1969.

-Chairman of the Division of Neurological and
Sensory Sciences and Professor of Neurosurgery,
Temple University Health Sciences Center, Phila-
delphia, Pennsylvania 1 9 HO.

or another and become integrated at na-
tional and international levels to become'
the policy-making bodies thai maintain
the' lewis of excellence which have char-
acterized out profession from the begin-
ning. We now find ourselves virtualb
.1 profession of organizations that should
fulfill e\ ei \ a< ademi< , intelle* tual, social
and political need ol the physic ian. I o-
day's instant communication and almost
instant transportation places every phy-
sician in instant contact; yet, the number of
organizations is phenomenal and if one
wishes and has the time and money, he can
be a full-time attender of meetings.

Why then, in the- organization-filled

WO] Id ol 1958, Was there the need tO de

\elop .! small neurosurgical society, in one
ol the country's lamest urban areas? At
that time, there existed four major aca-
demic neurosurgical programs within the
city of Philadelphia. There was, however,
vci\ little communication among them.
I1k'\ might just as well have been prac-
ticing and functioning 111 dillerent cities.
The senior neurosurgeons knew each other
quite well, bui then junior staffs and resi-
dents were very often only casually aware
of other neat In neurosurgical wot Ids and,
most important of all. no one program
knew what the other was doing. In addi-
tion, there was no local grouping of neuro-

281

282

I KI 1)1 RI( k Ml R I \(,ll |K

surgeons to represeni the specialty poliii-
call\ .11 the state and national levels. Ii
was line thai lhe\ saw eadi othei at na-
tional meetings, Inn al lids lime lliey were
more intent upon sitting and talking with
old friends from greatei distances, and die
national societies had little or no concern
for die local problems ol neurosurgical
|>i .a I i< e.

Dr. Rudolph |aeger, Piolessoi ol Neu-
rosurgery al Jefferson Medical (College,
was disturbed by this lack ol communica-
tion within die (il\ and wished lo do

something about it. It was his Eeeling that
the years ol provincial rivalry and com-
petition were coming to an end and he
fell dial there was a need lot die develop-
ment ol a local group ol neui osurgeons lor
die exchange ol ideas, lie discussed lids
concern with l)i. Michael Scott, Prolessoi
ol Neurosurgery at Temple University
Medical School. who supported his
views. The\, in turn, spoke with Dr. Robert
(.roll, Prolessoi ol Neurosurgery at the
University ol Pennsylvania, and I)i Vxel
Olsen, Prolessoi ol Neurosurgery al Hah-
neniann Medical College. The upshot of
this conversation was that these four men
held .in impromptu dinner at a Greek
resturanl in downtown Philadelphia early
in 1958. The) were unanimous in the
opinion that a society should be formed
within die cil\ to Eostei the specialty ol
neurosurgery and to develop closer inter-
professional relationships for the practi-
tioners ol this specialty. Ii was also their
feeling that, in order to insure the partici-
pation and membership of all neurosur-
geons in Philadelphia in the society, Dr.
Charles Harrison Frazier (1870-1936), for-
merly Professor of Neurosurgery at the
University of Pennsylvania and a pioneer
in the specialty, should be the patron of
the society and that its presidency should
be on a seniority basis, beginning with
Dr. Francis Grant as first president and
Dr. Temple Fay as first vice-president
and president-elect. It was obvious that
they needed a workhorse for this embryo

organization, and by some means which I
have never been able to ascertain, I was
selected to be secretary-treasurer. This
was a most fort nitons decision foi me be-
cause it gave me the opportunity to meed
know, and become friends with many col-
leagues whom I might not otherwise have
had die- opportunity to see. In addition, it
led to the line experience of helping to
develop a medical organization from the
\ ei \ beginning.

I In Inst formal meeting of the found-
ers' group was held at Weber's Tavern on
Montgomery Avenue, Ardmore, Pennsyl-
vania, in the fall of 1958. Dr. Francis Giant
presided; Dr. Temple Fay was vice-presi-
den( and Dr. Frederick Murtagh was secre-
tary-treasurer. Drs. Rudolph Jaeger, Rob-
in (.roll, Michael Scott and Axel Olsen
formed the initial Council of the organi-f
zation. The first order of business was for
each nieinbei present to contribute ten
dollars, not only to pa\ lor the meal, but
also to start the treasury. There was no
cjuestion among these present that the
society should be named the "Philadelphia
Neurosurgical Society," and that the late
Dr. Charles Frazier should be its patron.
Discussion of the scope of the organization,
however, led to some differences of opin-
ion. It was obvious that if the group was
confined to Philadelphia neurosurgeons
there would hardly be enough members to
form a good journal club and that the
group might not survive because of lack of
strength. It was evident that the neurosur-
geons in Pittsburgh, Wilmington, Balti-
more, and Washington, D.C. shared die
same lack of communication with us and
with each other within their cities. In
addition, there were a number of neuro-
surgeons practicing in main communities
outside of the large urban areas. It was
agreed that invitations to join the organi-
zation would be extended to neurosurgeons
in this geographical area and, if enough
interest was generated, the scope of the
organization could include the region of

I'llll Mil I I'll! \ \l ( R.OS1 R.GK \l SO( M l J

283

FlC. I. Photograph (akin al the lirst general meeting of tin- Philadelphia Ni'iirosurgica]
Society, Jefferson Medical College, Max l">, 111.")!). Scaled (left to right): Drs. Rudolph
[aeger, remple Fay, Robert (.mil. Standing (left to light): I)is. Michael Stoti, Frederick
Murtagh, fr.

Pennsylvania, New fersey, Delaware, Mary-
land, and Washington, D.( I.

The In si general meet in» oi the Societ)
was held on Ma\ 15, 1!).")!) at the Jefferson
Medical College. Dr. Francis (.rant pie-
sided ovei the scientific session, which was
a Symposium on Pain. The meeting was
attended In :!!) neurological surgeons, not
onl\ from Philadelphia and other loca-
tions in Pennsylvania, hut Erom New fersey,
Delaware, and Washington. D.C The
dinnei which followed the scientific ses-
sion was held at the Benjamin Franklin
Hotel and presided over by Dr. Temple
Fa) in Dr. (.rant's absence. At its business
meeting, the organization was ratified by
all members present, who became the
charter members ol the organization. Ii

was voted to reiain the name "Philadel-
phia Neurosurgical Society" in spite ol
the wider geographical distribution ol its
membership.

The Society thrived and flourished,
becoming a loi inn lot local neurosurgeons
to express theii ideas and to know each
other better. It also became the recog-
nized organizational both ol neurological
surgeons al each ol ilit- pertinent state-
levels.

1 1 was policy to have two meetings per
year. The spring meeting was usnalh held
at the home-base of the president. The
first eleven presidents were chosen in order
of seniority:

1. Dr. Francis Grant, University of
Pcnns\ ha nia

284

I Rl DI.KK k Ml K I |K

2. Dr. Temple Fay, Temple University
.S. Dr. Rudolph faeger, Jefferson Med-

i< a] ( College
I. Dr. Hugh Fulcher, Georgetown Uni-

vei x i i \

5. Dr. fames Watts, George Washing-
ton Univei sity

(i. Dr. Robert (.roll. University ol
Penns) Ivania

7. Dr. fames Arnold, University ol
Mar) land

S. l)i. Slew, ul Roue. University ol
Pittsburgh

'). Dr. Michael Scott, Temple Univer-
sity

10. Dr. William Speuee, Washington,
DC.

11. Dr. Axel Olsen, Hahnemann Med-
ical College

The practice ol naming the president
In seniority was easy at In si because there
were so lew neurosurgeons that then se-
niority could easily be established.
More recently, however, the establish
men) ol seniority has become nunc diffi-
cult when sometimes only a week or a
month or two would separate the candi-
dates lot presidency. This practice was
therefore abandoned in 1969, and it is
m\ honoi and privilege to be the In si
elected president of the Society.

I'he I. ill meetings ol the Society were
usually called at the invitation of one of
the members. Consequently several inter-
resting meetings were held in Wilming-
ton. Delaware, and Allentown, Harris-
burg, Hershey, and Sayre, Pennsylvania.

In 1962, the Pennsylvania State Med-
ical Society invited us to meet in con-
junction with their fall meeting. This was
done for three years. We found that this
practice more or less dictated the time
and place of our meeting, as well as the
format, and so it was discontinued in
1965.

My tenure as secretary-treasurer lasted
from 1959 until 1966. As we were writing the

by-laws and constitution, I was careful to
have it read that the secretary-treasure!
could serve for three years only and not
succeed himself. At the end of my first
three years, however, I found that this state-
ment was mysteriously missing at the time
the bylaws and constitution were accepted
by the Society. It was my pleasure, therefore
to serve for another three years. However,
since I have strong personal convictions
thai no one pe rson should be in such a
position for more than seven years, I re-
signed in 1966 for the good of the Society
and was succeeded by Dr. Arthur li. King
of Sayre, Pennsylvania.

As the Society grew, it became increas-
ingly involved as a policy-making body
at the state level with problems relative
to the practice of neurological surgery.
This woikcd well for the Pennsylvania
members, but it became rather cumber-
some lot neurosurgeons in Delaware,
Maryland, New Jersey and Washington,
D.C., to state that they were represented
by the Philadelphia Neurosurgical So-
ciety. The name Philadelphia Neurosur-
gical Society had been challenged several
times because of the geographical scope of
the organization. Each time the question
arose, however, it was decided to retain
the name in honor of the origin of the
group. An additional problem arose with
its confusion with the more venerable
Philadelphia Neurological Society. And
to confuse matters even more, in 1964, I
was not only secretary-treasurer of the Phil-
adelphia Neurosurgical Society, but also
served a term as president of the Phila-
delphia Neurological Society.

In 1967. the matter came to a head and
it was obvious to everyone that a more
appropriate name would be "The Mid-
Atlantic Neurosurgical Society." There-
fore, in 1967, the former Philadelphia
Neurosurgical Society passed into history
to meet the changing needs of growing
membership.

Dr. Max Pcct and His Contributions
to Neurosurgery 1

/>v IM II I.I I' I ). ( ■( >KI >Y, m i)

II is quite appropriate that the profes-
sional accomplishments and the in-
triguing man thai was Dr. Max Minor
Peel he discussed at diis meeting <>l the
medical history section of The College of
Physicians <>l Philadelphia, rhough Dr.
Peet was a graduate of the University of
Michigan Medical School in the Class of
I910, he received his postgraduate training
in surgery al the Hospital of the Univer-
sity of Pennsylvania in Philadelphia w here
he worked with Di. Charles II. Frazier.
As a result of this expel ieiu e, he developed
an earl) interest in the surgeiy of the ner-
vous system.

He returned to the University ol Mich-
igan in I916 a> an Instructor in Surgery.
The limited amount ol neurosurgery done
al thai time was carried oul In Dr. Peet.
B) he confined his ellorls to the sin -

gen ol the nervous svstem and. in I<>30
he was named Professoi ol Surgeiy in
c harge of the Division of Neurosurgery.

His two major areas ol interest were the
surgery of tic douloureux and his proce-
dure ol splanchnicectomy for hypertension.
He learned the procedure of differential
section of the sensory root of the trigeminal
nerve under Dr. Frazier, and he became
an acknowledged master ol the procedure.
He devised the operation ol splanchnicec-
tom) loi reliel ol hypertension and even-
tual!) (.ni ied out over 1800 of these pro-
cedures.

The major interest of a scientific nature
which Dr. Peel had aside from neuro-

1 Section on Medical History, The College of
Physicians of Philadelphia. 18 November 1969.

-Professor and Chairman. Department of Neuro-
surgery, Jefferson Medical College, Philadelphia,
Penns) Ivania 19107.

logical surgeiA was ornithology. I his in-
terest began in high school and continued
throughoiii Ins life. He was responsible
loi numerous original observations and
eventually acquired the largest private
bird collec i ion in the world.

To those of us who trained under him,
Dr. Peet will be remembered noi only as
a master surgeon, but also as a vei \ human
person with a keen sense of humor, some-
times needling, bill always kindh, towaid
his "bo\s."

Fig
(1885-

I'hotograph of Dr. Max Minor Peet

1949).

285

The Massa Hoax 1

By R V )l< I ( )\ I [ALL, m.d

DR. GIANAKON, distinguished Fel-
lows ol (he College .iikI honored
guests . . . higher primates all.
Perhaps never before in the hisioi\ ol
I he College ol Physicians of Philadelphia
has a guesl speaker been so accurate when
I sa\ thai ii is with humility and an aware-
ness ol undeserved privilege and dubious
honoi thai I am here tonight. Behind the
august facade ol the College resides a warm
sense ol humor . . . and I thank you.

The title which appears on tonight's
program is The Massa Hoax; 1 1 it- unpub-
lished subtitle is. The Day We Made
Monkeys of Ourselves and Some Others.

Monkey business is nothing new to the
medical profession <>t to any other area ol
human endeavor. In fact, it we believe
uhal Desmond Morris tells us, and main
of us had come to the same conclusion
before the printing date ol Hie Xaked
Ape, all human business is monkey busi
ness. Ii is small wonder, therefore, thai
.in ape sioix like ouis generated as much
human interest as ii did. Retail, if you
will, the- most popular cage at the ZOO, or
the best act in the- menagerie. And,
ol course, there has never been any-
thing to top c inema's King Kong.

Our monkeyshines started quite inno-
cently at the scrub tanks of the neurosur-
gical operating suite in the Hospital of the
University ol Pennsylvania. In the early
morning hours of a bleak Thursday after
a grim Monday, Tuesday and Wednesday,
the other residents and 1 were discussing
the surgical approach to a pending case.
The head scrub nurse uncoupled my train

1 Section on Medical History, The College of
Physicians of Philadelphia, 18 November 1969.

- Department of Neurosurgery, Hospital of the
University of Pennsylvania, Philadelphia, Pennsyl-
vania 19104.

ol though) with hei customary inquiry!
"Notion, what's on the schedule for to
tnoi row?"

\i thai point in lime 1 couldn't tell her,
bin i his was unacceptable. So, she persisted
to inquire. In desperation, to get her off
m\ b.nk, I turned slowly and deliberately
from the sink, glared across the top of my
mask, and said "Would you believe it,
a gorilla?"

Her lower jaw dropped bom a grinless
lace and hei eyes seemed to get bigger. It
was truly a look ol shocked belief. She
look a hall-step backward, tilted her head
to the side and said, "I never know when
to believe you. But I won't believe it un-
til 1 see it on the O.R. schedule." It was
ai that moment that the Massa Hoax was
boi n.

We then entered the operating room,
gowned and gloved, and began the opera-
lion. Our worried nurse scampered into,
around, and out ol the room, back and
forth, as head O.R. nurses are wont to do,
and engaged in conversation with the anes-
thesia resident, as they are also wont to do.
The subject ol the conversation was to-
morrow's case: an operation on a gorilla.

I iniisi admit that il was as a result of
listening to their conversation with one ear
thai I picked up enough information to
make my gambit plausible. I had com-
pletely forgot about Massa (Figure 1); I
didn't even remember his name. I had
not seen the story in the newspaper about
his recent surgery. I didn't even know that
he was sick. 1 was also unaware of the fact
that two of our staff men, one from anes-
thesia, the other from otolaryngology, had
participated in the operation to drain
Massa's infected paranasal sinuses. It was
the anesthesia resident who indirectly in-
formed me that Massa was the oldest liv-

L'liu

I 1 1 1 \l VSS \ HOAX

287

i 1 1 14 gorilla in (.i|)ii\n\ .iikI thai his vital
statistics included 300 pounds "I weighi
and (3 feet of hci,s» h t. "Oh yes, and his hair
is S iii( I it's in length," added the 11 111 sc.

Immediately after surgery, 1 weni t » ►
the schedule board and wrote in the name
fMassa" undei "Patient" and "Right
frontal craniotomy" undei "Procedure."
I'oi the patient's location, I scribbled,
••Room 200," making the "2" look like a
"Z." With .is much nonchalance as I
could muster. I went back to the scrub
nurse and told her to check the schedule.
r>\ (his time she was no longei surprised.
She hail ahead} convinced herself, as well
as a lew ol hei friends, thai we were, in
lac t, going to operate on Massa.

I explained, lot the benefit ol the skep-
tics, that Massa's frontal sinusitis had
worsened and eroded through the base of
the skull, forming .1 brain abscess. Since
the University of Pennsylvania had figured
prominently in his earlier management,
by cooperative efforts between the School
of Veterinary Medicine and our Depart-
ments of Anesthesiology and Otolaryngol-
ogy, it was only reasonable that we in the
Departmeni ol Neurosurgery should be
consulted for the obvious complication at
hand. "After all, human medicine and
monkey medicine are not that far apart.
Don't \ou remember Able and Raker?"

All of this was accepted at face value,
as well as the need for doing such deli-
cate surgery in familial surroundings with
0111 own instruments and nursing team
and our own anesthesiologists. And, "Fur-
thermore, only Oscar knows how we like
our heads shaved."

I then went to two stall men in anes-
thesia who cover our service to explain the
real situation and to request their in-
dulgence. The story tweaked their fancy,
and they both became accessories before
the fact.

Thus the plot was laid and thickening
by the minute; by 3 P.M. that afternoon

FlG. I. Photograph of Massa the gorilla, age 'M
years. (Courtesy of the Zoological Society of Phila-
delphia.)

the silicic. il schedule was printed and cm
culated. Operation Massa was launched!

There were main calls throughout (In-
day concerning details thai had to be con-
sidered to ensure a successful outcome lot
surgery. "What about the lice and the

fleas?", one asked. "Oh," I said, "thai is
no problem. We'll put him in a large
plastic bag with just his head and an aim

sticking out." "What aboul the table, is it
big enough?", another queried. 1 said,
"We plan on using two tables, side by
side."

"Where was he to go after surgery, to
l.G.U. or to the usual Recovery Room?"
"Who would be selected from the nursing
registry i<> be the private duty types?"
All ol these and many other matters had
to be considered and resolved. We had no
idea that there was actual competition
between the nurses ol the Recovery
Room and the I. CI '. Kac h group thought
that they could give better care than the
other. To grease our palm, the Recovery
Room people granted us the use of an
entile bay. the one with all the monitor-
ing devices for anesthesia researc h.

Our plan of attack was quite simple.

288

R. NOR I C)\ II \l I,

Massa was to come to the hospital on the
morning ol surgery, aftei the rush houi
traffic, ol course, in the ha< k ol .1 large
van with a hydraulic tailgate lift. He was
to have chains on both ankles and wrists,
as well .is one around his neck. He was
io he escorted by five chain men and his
Eavorite handler. Massa would entei the
hospital complex llnough the hack en-
trance and would ascend to the operating
loom suite by way ol the height elevator.
He was lo he walked, or whatevei gorillas
do. down the hallway in his new plastic
siiii lo O R. Id wheic he would he coaxed
onto the two tahles and would then, on .1
given signal h\ his lavoiilc handler. ex-
tend his .11111 docilely so anesthesia could
he indue eel intravenously.

Obviously the patient would he N.P.O.
Erom midnight before, and he would be
given no sedation lor leai ol 1 1 1 «. - deadh
combination ol increased intracranial
piessure and respiratory suppressants.

Oscar, the ne ui osui gic al orderly, who
positions and shaves .ill ol oui patients,
had been forewarned. Thus he became
Eorearmed In collecting no less than seven
surgical prep trays to assure a good job in
baring the ape 's arms and seal]).

The woid had spread, apparently, and
volunteers to scrub from the ranks ol the
nurses, medical students and interns, were
last accumulating. F01 those who didn't
think the) had a chance to have a hand in
tlit- opeiaiion, places ol ohservation were
marked in the' O.R. and were jealously
claimed. There were sixty such places
arranged by Friday morning.

Not to be outdone, the Department of
Radiology was on record to render what-
ever service it could in the way of skull
films on the morning of surgery. And, in
fact, at one point the) had a few people
looking through their department for Dr.
flail and Massa who were both down I01
skull x-rays.

By this time, an attest to the efficacy of
the hospital grapevine, not only were the

professional and paramedical personnel
informed, and in some depth, hut so were
some eil the patients. One ihoughilul pri-
vate patient on our service called the Wil-
liam Penn Shop and iccpiested that a
bunch of bananas he delivered to Massa
posl-opeialivcly, in care ol the University
I [ospital.

Thai night when 1 went to bed, 1
thought the Massa incident would also
sleep. However, the next morning, the
operating suite was alive with cameras and
people. It was obvious that some had never
before been in an operating room: many
wore scrub suits, caps and masks in place
over their street clothes. The place was
abuzz with activity and excitement in antic-
ipation of the moment ol Massa's arrival.
Meanwhile, in the neurosurgical area,
Oscar was having some serious second
thoughts, and the other orderlies, those
who could be found, were on the verge of
mutiny.

It was time, 1 thought, to let the mon-
key out ol the bag, so to speak. 1 called
a hurried council of war with the rest of
the residents. It was decided that I should
go to the- master O.R. schedule, draw a
broad pencil line through Massa's name,
and pi int in big letters "Cancelled." It
was also decided that a story of explana-
tion was needed, one that would mull the
disappointment of believers. So, once again
we concocted a story.

You see, as I stated earlier, Massa had
been X.P.O. since midnight. The truck-
driver made a wrong turn and brought
the van to a halt, not behind the Ravelin
Building, but behind the Food Services
Building where the aroma of fried bacon
and fresh coffee enriched the already
scented atmosphere of early morning
Philadelphia. A\ lien the doors of the van
parted, the starved beast had an uncal fit
and hurled his handlers about in a rage,
rendering the entire situation unsafe for
both man and beast. Only with great
effort was Massa subdued and locked into

I III M \ss\ How

289

the van. With sadness, the powers that be
decided to cancel surgery for today. They
would try again another time, but next
time at the /no.

Apparently this story was accepted,
and with gusto, for by the time it had
worked its way off the O.R. floor f didn't
recognize it. ft seems that someone had
reported visiting the Receiving Ward and
finding it a shambles. We heard there
were people lying all over the place with
chain marks on their heads and torsos,
beaten into near senselessness by the en-
raged and starved gorilla.

After this misreport, we thought that the
event of Massa's craniotomy had come
and gone, and was, for all intents and pur-
poses, over. We returned to our daily
routine with a chuckle.

Later that day, I was summoned to the
Office of Public Relations to explain the
sudden increase in telephone calls to the
hospital inquiring about Massa, his diag-
nosis and post-operative condition. So I
explained the hoax. Before I was finished,
however, the P.R. girl was on the phone
to a "friend" on the staff of the Evening
Bulletin. He was interested in clearing up
the matter, not on reporting it. The City
Editor had been given a tip by a reliable
informant but couldn't track down the
story. Since it was nothing more than a
hoax, he was sure that it wasn't news-
worthy. With reassurance that I had finally
squelched the tale, I left, again convinced
that I had seen and heard the end of the
Massa hoax.

The next day everything seemed back to
normal. Rounds went as usual and spirits
were high. The neurosurgical residents
agreed that it had been a good joke, and
that the best part of it was its harmless-
ness.

Later that afternoon, while napping in
the on-call room, I was awakened by a
telephone ring. It was an outside long
distance person-to-person call from, ac-
cording to the voice at the other end, the

Mike Jackson Show from KABGTV in
Los Angeles, California. As she talked I
heard the time beep, yet was convinced
that someone was playing a joke on me.
I hung up, telling my caller that I was
very busy, but that may be at a later date
we could talk about it over a drink or two.

I went back to sleep, only to he awak-
ened shortly by another call, this time
from a recognizable voice. It was one
of my residents who claimed to be reading
from a newspaper story about Massa. I
bolted out of bed and was immediately
awake, taking a shower in my own cold
sweat. Despite my initial reaction, I was
still not convinced of the validity of this
call cither. I decided to make myself
scarce for awhile. Naturally, the first place
I went when I left the confines of the
hospital was to the local newsstand.

There it was, on page one, in headlines:
"CRANIOTOMY ON MASSA— JUST A
SURGEON'S JOKE." The spoof was on
the hourly newscasts throughout the day
and apparently made the national wire
service. It was also the funny ending for
the 11 P.M. local TV news. Since that
time I have received numerous letters from
all over the United States and its terri-
tories, telling me of the appearance of our
gorilla story. A few writers have enclosed
newspaper clippings.

To date, the farthest newspaper known
to carry the story was Puerto Rico's San
Juan Star, delivered to Saint Croix in the
Virgin Islands. Moreover, friends are still
sending me pictures of apes and the O.R.
nurses have presented me with a small
plaster gorilla with his hands holding his
head.

The Philadelphia Zoological Garden,
this country's first and best zoo — related
not only by parentage, but also by con-
tinued happy association to the Univer-
sity of Pennsylvania — has remained
friendly. Their public relations depart-
ment has provided a display for the Col-

290

R. NORTON HALL

lege foyer and Dr. Fred Ulmer personally
took a color photograph of Massa for to-
night's talk. I assume that the gate receipts
increased at the zoo for two weeks after
the craniotomy story.
In conclusion, I suppose that the Massa

hoax was a personal experience of more
worth than I can now appreciate. For it
was my first encounter with practical an-
thropology and group dynamics. The only
expressible insight derived therefrom is:
"Well, I'll be a monkey's uncle!"

Multiphasic Health Testing 1

By JOSEPH H. BOUTWELL, ph.d., m.d. 2

I WANT to thank the Pennsylvania
Public Health Association and the Sec-
tion on Public Health of The College
of Physicians for the pleasurable oppor-
tunity and the high honor which was be-
stowed upon me, through your Program
Committee, when I was invited to speak
to you today.

Although I come to you from Atlanta, I
am honored to claim a number of you in
the audience as friends. Dr. Claude P.
Brown, whom I met soon after I arrived in
Philadelphia in 1949, was very thoughtful
in sending me an assortment of printed
memorabilia of Dr. Arthur Parker
Hitchens, in whose memory we are gath-
ered here today. I never had an opportu-
nity to meet Dr. Hitchens, as his death oc-
curred in December of 1949, only six
months after I started my appointment at
the Department of Biochemistry of Tem-
ple University Medical School. Dr. Hit-
chens was a laboratorian, a bacteriologist
and a public health epidemiologist. He
had, I deduce from his activities, a strong
sense of the professional community of
understanding which is a necessity for
scientific communication. His leadership
in the founding of Abstracts of Bacteriol-
ogy, his support of Biological Abstracts,
his contributions to Bergey's Manual and
to the Diagnostic Procedures and Reagents
of the American Public Health Associa-
tion all attest to this, as do his efforts in
the publication of The Journal of Bac-
teriology. His wife, Ethel Bennet Hitchens,

•Arthur Parker Hitchens Lecture XIII, The Col-
lege of Physicians of Philadelphia, 8 December 1969.

2 Chief, Licensure and Development Branch, Lab-
oratory Division, U. S. Department of Health, Ed-
ucation, and Welfare, Public Health Service, Health
Services and Mental Health Administration, Na-
tional Communicable Disease Center, Atlanta,
Georgia 30333.

has insured that The College of Physi-
cians will continue to be able to maintain
that journal in the College library.

It is perhaps fitting that a clinical chem-
ist be recruited to discuss multiphasic
screening, a technique or procedure
which, it is hoped, will contribute to the
ability of the health profession to control
long-term (or chronic) illnesses in the same
way that the diseases associated with mi-
crobiological causes have been controlled.

The purpose or purposes of multiphasic
health testing should be clearly under-
stood. Unless the purpose (the end result
sought) is very clear to all (including those
concerned in the required secondary sup-
plemental decisions), much confusion and
waste can result.

First, let me outline what I consider to
be included in multiphasic health testing.
In addition to the bookkeeping necessities
for patient identification, the first phase
of multiphasic health testing includes a
review of past medical history, family his-
tory, personal habits, and a pertinent
interval history of changes in those items.
Such information may be obtained by
various time-saving techniques, such as a
self-administered questionnaire.

The second phase of the system com-
prises programs for system and organ
testing. Supplementing the procedures used
in the collection of data for these systems
are laboratory testing methods.

The mere enumeration of the systems
to be examined shows that some economy
of effort and design must be relied upon
to insure a workable system of multiphasic
health testing. The decisions needed to
direct the procedure effectively can be
guided by examining the purposes of
multiphasic health testing.

The most obvious purpose is to bring

291

292

JOSEPH H. BOUTWELL

to bear upon each member of the pop-
ulation those medical and laboratory pro-
cedures now known to be helpful to the
physician in detecting and monitoring
disease. This is to say that even without
the development of new medical criteria,
without any new diagnostic aids, our pres-
ent techniques can be more widely and
effectively applied to detect unknown or
untreated disease. The same purpose is
served by surveillance of healthy individ-
uals and of patients known to have de-
fined diseases such as hypertension and
diabetes.

Physicians can effectively use the same
type of multiphasic health testing for their
office practice, for preemployment and
periodic health examinations, for insur-
ance examinations, and also for pread-
mission workups of patients to be hos-
pitalized.

To fulfill these specialized purposes and
to provide for in-depth investigation of
abnormalities revealed during the test
period, routine multiphasic health test-
ing should include a fairly large number
of more specialized sub-routines, such as
examinations of high risk groups.

The present great interest in multi-
phasic health testing stems from a diver-
sity of purposes based on beliefs, hopes,
and concerns, some of which are well
founded. Others, I believe, presuppose
the existence of certain non-existent in-
formation. Here are some examples:
1. It is believed that there is at present an
inadequate application of present tech-
niques.

Multiphasic health testing is proposed
as the mechanism by which our present
medical capabilities in disease detection
and treatment may be more effectively
and economically applied. This may be
true. On the other hand, the present
system of physicians' offices, clinics,
neighborhood health centers, and other
approaches combined with more cen-
tralized laboratory services may afford

a better utilization of resources. The
social and economic consequences of
ill-considered choices between alterna-
tives may be serious.

2. It is believed that technological de-
velopments in laboratory and diagnostic
apparatus have lowered costs.
Undoubtedly, in the last 15-20 years,
enormous strides have been made and,
in some cases, the cost of a single analy-
sis has decreased significantly. Caution
in interpreting this fact must be urged,
since the lowered costs have generally
resulted only in more tests on any given
patient. The increased technological
capacity has not been applied to dis-
ease detection in populations. Thus, the
capability of significantly extending
case finding by these means has not
been tested. It should be recognized
that the requirements and techniques
and procedures are quite different for
these two applications.

3. // is believed that technological de-
velopments have increased accuracy and
precision.

Automation has been shown, rather con-
clusively, to increase precision, or the
reproducibility of the results of clinical
laboratory tests, when the process is
well controlled. This advantage, how-
ever, is not an element which accom-
panies the instrument as an integral
part of the product. It is rather a po-
tentiality which can be achieved only
by knowledgeable, experienced analyt-
ical personnel. The more "sophisticated"
analytical instruments, even those more
recently developed, depend heavily upon
calibration reference materials and
standardization techniques of dubious
parentage, and these instruments re-
quire even greater degrees of profes-
sional acumen for accurate and de-
pendable results than do classical
methods. The report of the recent sym-
posium on Multiple Laboratory Screen-
ing underlines this problem by stating

Mil/urn ask: m ai in i rs mm,

293

that the "precision and accuracy of
present analytical methods are limiting
our ability to use this approach."
What are the beckoning possibilities
which multiphasic health testing, or mul-
tiple laboratory screening, places before
us? First, the possibility that by well or-
ganized use of the resources for diagnosis
and treatment, a greater number of per-
sons with disease may be diagnosed and
treated. Second, the possibility that with
earlier detection of disease and more fre-
quent and effective monitoring of disease
treatment, the effects of disease on the
patient may be minimized. Third, the
possibility that this system of coordinated
approach to health care may lead to more
effective diagnostic tests or to more useful
combinations of presently existing labora-
tory methods. An example of the former
is the test of newer methods of detecting
breast carcinoma organized by the Health
Insurance Plan of New York and, of the
latter, the efforts of Files and Lindberg
at the University of Missouri.

A number of relatively well defined pro-
fessional responsibilities are yet to be as-
sumed, discharged, and assimilated into
the medical diagnosis and treatment cul-
ture before this most intriguing prospect
of multiphasic health testing can be re-
garded as within our grasp. Most vitally
important is the improvement of the ac-
curacy and precision of the laboratory
methods and other procedures used to
accumulate the primary data upon which
the physician must base his interpreta-
tions.

This next step will be to enter upon the
task of defining "normal values" for dis-
tinct populations with the variants of age,
sex, dietary history, etc., in a way similar
to that taken by an earlier generation in
defining a "normal BMR." Once the limi-
tations of laboratory error and inadequate
definitions of the normal range are re-
moved, we can move on to the next step:
the definition of normal values (and their

range) for each individual. Deviations
from one's own individual values may
assume great importance in the early de-
tection of disease. The last step, which is
already being explored, is the detection of
disease by slight alterations in the pattern
of normal relationships between several
test results.

These beckoning possibilities are so in-
triguing and so enticing that we may well
overlook, indeed some very influential
leaders are presently overlooking, the im-
mense scientific labor and investment neces-
sary to build the required firm foundations.
I am very concerned that in our apprecia-
tion of the desirability of the more distant
goals, we do not fail to see that the very
next immediate tasks are begun. Already,
the market place is replete with analyt-
ical instruments and systems, reagents,
and devices inadequately designed and
tested which can only deliver informa-
tion of poorer quality than do the clas-
sical methods. There seems to be a philos-
ophy that a large amount of low quality
(low in accuracy and/or precision) infor-
mation is equivalent to a smaller amount
of high quality data. Although this view
has some validity in establishing true mean
values by accurate (if not precise) meth-
ods, it is not at all useful for individual
patients.

Three more general areas should be
mentioned. First, if the amount of infor-
mation (both laboratory data and other
pertinent system review data) is to be
multiplied manyfold both by having more
patients and by having and keeping
more information on each patient, a much
more effective system of data handling,
storage, and retrieval must be developed.

Second, the need for computer assistance
in interpreting medical and laboratory
data must be recognized and its use ex-
ploited. And, third, the need for effective
management and organization of the mul-
tiphasic health testing system must be

294

JOSEPH H. BOUTWELL

emphasized. This need for good manage-
ment practices must be recognized at all
levels from the narrow base of the day-to-
day operation of the integrated system to
its interaction with community health
problems. Categories of disease must be
given their proper weight and importance

in the total concept of community serv-
ices. Multiphasic health testing systems
must be optimized not only from the
viewpoint of how most effectively to de-
tect, treat and follow disease, but also from
the viewpoint of the individual's total
life in the community.

Philadelphia Medicine in 1841 as Seen by
a Visiting Physician

By HAROLD J. ABRAHAMS, ph.d.

MILO LINUS NORTH (1790-
1856), B.A., Yale, 1813, M.D.
(Honorary), Yale, 1834, of Sara-
toga Springs, New York, visited Philadel-
phia in the winter of 1841-42 with the
purposes of enjoying the sights of a large
metropolis and of enriching his training
in medicine by learning and observing. He
attended lectures at the Jefferson Medical
College and the School of Medicine of the
University of Pennsylvania, visited the
famous hospitals of the city and sought out
the company of its physicians.

Upon his return to Saratoga Springs, he
set down his impressions of Philadelphia
medicine in the form of three "letters,"
and submitted them to the editor of the
Boston Medical and Surgical Journal,
where they were published (Volume xxvi,
1842, pages 5-8, 25-29 and 39-45). He
gives as his reasons for writing them, that
he had the itch to write, that he had an
abundance of free time during the long
winter when Saratoga had few visitors,
that it was his wish to tell his colleagues in
the Northern states something about
Philadelphia medicine, and, finally, that
he felt "a sense of deep obligation . . . for
the professional kindness, liberality and
attention bestowed on a stranger by the
excellent physicians" of Philadelphia. He
remarks: "I do not suppose that my case
was peculiar. These men must be in the
practice of giving the hearty welcome to
those who come in quest of science."

• Research Associate, Library of The College of
Physicians of Philadelphia, 19 South 22nd Street,
Philadelphia, Pennsylvania 19103. Dr. Abrahams
resides at Wcssex House, St. Davids, Pennsylvania
19087.

t Historian, National Institutes of Health, Be-
thesda, Maryland 20795.

* and WYNDHAM D. MILES, PH.D.f

Facts about Dr. North's life are few in
number. He probably studied medicine
under a physician and may also have at-
tended medical school lectures somewhere.
It is known that he practiced medicine in
Hartford in the 1830's and moved to Sara-
toga Springs in 1839. While practicing in
the latter place, he became a most enthu-
siastic exponent of Saratoga waters, pub-
licizing their virtues in articles in the
Boston Medical and Surgical Journal from
1 839 — 4 1 and in a small book, Saratoga
Waters, or, The Invalid at Saratoga, which
ran through seven editions between 1840
and 1858 and belonged to the genre of
other such books by practitioners residing
in Saratoga and treating its visitors. At
the time of his death on February 22, 1856,
at his son's home in Spuyten Duyvil, New
York, the editor of the Boston journal ex-
pressed the hope that someone would write
an obituary notice about him, but an ade-
quate biographical sketch of Dr. North
has not yet come to hand.

North's impressions of teachers and of
the social customs of physicians evoke a
picture of the old Philadelphia medical
scene that is not described in formal his-
tories and biographies. His chatty, per-
sonal recollections give a view of Philadel-
phia medicine as it existed one and one-
third centuries ago.

Below are reproduced Dr. North's "let-
ters," omitting only those portions which
do not illuminate his impressions of
Philadelphia medicine of his day. The
letters capture some of the spirit of
nineteenth century medical Philadelphia
and thus constitute a worthy eye-witness
account of some of the phases of medicine
in the middle decades of that century.

295

■2'u

HAROLD J. ABRAHAMS AND WVNDIIAM D. MILES

On Wednesday, 27th October, 1841, I
took up my residence for the first lime in
the City of Brotherly Love, at a private
boarding house, corner of Eighth and
Walnut. Although I was furnished with
several introductory notes in New York, I
first sought some of my invalid acquaint-
ances, and through them their family phy-
sicians. As my real object, however, in
visiting the city was the acquisition of
medical science, whether gained in private
conversations, lectures, hospitals, libraries,
museums or medical clubs, I soon aban-
doned all formality, and without hesita-
tion made my own introduction when it
was not perfectly convenient to obtain the
medium of others. As my name and resi-
dence had become generally known to the
physicians through the frequent visits of
their patients to the Springs, credence was
readily obtained, and thus needless for-
mality avoided. During an abode of three
weeks, I was made unceremoniously a
guest in the families of several, and at
many of their private libraries and offices,
and was admitted to various hospitals and
to courses of public and private medical
instruction. I was also politely invited to
several medical and scientific clubs, of
which it may be proper to speak in this
place.

All the Medical Clubs I attended were
very similar. Some dozen medical men as-
sociate and meet once a week at each
others' houses in rotation, after the labors
of the day are over. The interview oc-
cupies say from 8i/ 2 to 10i/ 2 P.M. The only
absolute rule that was apparent was that
the refreshments should be rigidly limited
as to variety. Cakes, coffee and tea and
biscuit comprised the whole. This, having
been long and fully settled, exempts the
family from trouble, and leaves the host
entirely at his ease and enjoyment. Indeed
there is not the least awkwardness nor em-
barrassment in the host's attending to an
incidental call. These circles were the
scenes of easy medical and scientific chat,

without stiffness or any sort of friction
from regulations; a place of relaxation and
mutual information respecting the sub-
jects that would naturally interest a set of
scientific professional men. The friendly
feelings generated and enhanced by these
meetings must serve greatly to lighten the
anxieties and cheer the labors of the mem-
bers of the circle. There was not the least
formality and no organization. Each one
came and went without ceremony.

I am thus particular respecting these
clubs, because I have long been an advo-
cate of their use in other cities and vil-
lages. There is scarcely a village so small
in New England that some dozen men
might not spend a couple of hours, once a
week or fortnight, in unceremonious con-
versation on miscellaneous subjects. In
cities, physicians can do this. It cannot be
denied that many clubs have failed. But,
on inquiry, the cause of failure will be
found in nearly every instance in the one
fact that the entertainments were not
limited, exactly and scrupulously, at the
commencement. This fault is not charge-
able to the selfishness, but the generosity
of the members: and if their families were
never sick, nor servants difficult to be pro-
cured, the failure would not occur.

The Wistar Parties in Philadelphia are
held every Saturday evening through the
winter, and are on a different basis. No
person can be a member unless previously
a member of the American Philosophical
Society. This renders it, "per se," a society
of distinction. They meet from house to
house, each member bringing a stranger of
proper character if he chooses. No ladies
attend. Among the distinguished Phila-
delphians present, I was proud to see a
very full representation of our own pro-
fession. The supper table was very sump-
tuous for a scientific body, and I deeply
regret to say that various kinds of wine are
yet placed on the table. Would these
noble-looking men, with their bright faces,
eloquent lips and glowing sentiments, be

PIIII.ADF.I.IMII \ MEDICINE IN 1 HI 1

297

more likely to withdraw from these social
gatherings if the wine should he dismissed
and the multiplied hospitalities of the sup-
per table be reduced to a simple repast?
Do I wrong these men, to whom I stand
indebted as an obliged guest, by supposing
that, if the secret thoughts of all their
hearts could be read, it would be found
that these fellow citizens of Franklin dis-
claim all connection between wine and
science, and heartily wish them divorced?

Before dismissing the subject of clubs,
indulge me in saying a word about a medi-
cal association in Hartford County, Conn.
About 17 years since, several high-minded
physicians in that county constituted
themselves into an election society under
the name of the Hopkins Medical Asso-
ciation, to embrace all in the vicinity who
seemed worthy and desirous of member-
ship. The terms of election were made so
rigid that it was next to impossible for a
dishonorable man to gain admittance.
They have met ever since, once in four
months, or three times a year. At first they
went from house to house in rotation. But
the remoteness of some of the meetings
from the city, the occurrence of an occa-
sional stormy day. and the liability of
sickness in the family of the host, nearly
destroyed the club.

At this juncture an intelligent manager
of a public house in Hartford, considering
that, owing to the peculiar engagements of
physicians, the distance of many, and
stormy days, he could scarcely have an
average attendance of over half of the en-
rolled members, offered to give them a
plain, substantial supper three times a
year for one dollar a member per annum!
By this arrangement the public house re-
ceives say forty dollars a year for about as
many meals, and some pretty little per-
quisites from horse-keeping, Sec, so that
they have given the club a large sitting
room and a meal three afternoons a year
for several years, and have never com-
plained. This arrangement could only-

have been accomplished in Yankee land,
but there it may be done in many other
cities and villages: and if both parties are
as happy as they have been in tins case,
they never will regret the undertaking.
The elective nature of the Society has had
a palpably beneficial effect on the profes-
sion out of the club, in restraining them
from dishonorable practices; and those
within are clearly much benefited by the
social and scientific exercises of the club.
Each meeting has an organized session be-
fore supper, devoted rigidly to medical
discussions and improvement: social pleas-
ures succeed. I commend this Society to the
consideration of the leading men of our
profession in the many localities in our
country that are populous enough to ad-
mit of such association.

But, omitting the further discussion of
clubs, let us pass to a different topic; viz.,
the comparative respectability of the medi-
cal profession in Philadelphia. I admit,
most fully, the fallacy of first impressions.
I know how differently men and things ap-
pear after a year's acquaintance and ob-
servation. Still I am confident there can be
no cause for reconsideration in asserting
that our profession hold a very high rank
in that city. Consider that there are three
flourishing medical colleges in the very
heart of the city, and near each other,
either of which would stand high in any
part of the country. 1 About the first of
November from seven hundred to one
thousand medical students and strangers
are, all at once, to be seen traversing the
streets and inquiring for the various medi-

1 The three schools were the School of Medicine
of the University of Pennsylvania, Jefferson Medi-
cal College, and the Medical Department of Penn-
sylvania College. The medical school of the last-
named college lost its independent existence when
it merged with the Philadelphia College of Medi-
cine in 1859, although the name was retained by
the school which resulted from the merger. The
new school, likewise, became extinct shortly there-
after. (See Abrahams, H. J.: Extinct Medical Schools
of Nineteenth Century Philadelphia. University of
Pennsylvania Press, I960.)

298

HAROLD J. ABRAHAMS AND WYNDHAM D. MILES

cal offices. This noticeable influx of strang-
ers makes its proper impression on the
citizens. It is a matter of commercial and
social interest. These students scatter into
many families, and medical men and med-
ical subjects become legitimate matters of
discourse. They spend the winter, and leave
to the boarding-houses, lecturers, book-
sellers, merchants, private teachers, Sec. Sec,
many thousand dollars. Even strangers can
see that medicine is a subject of general in-
terest in Philadelphia. When comparing
these flourishing medical schools with
literary colleges, law schools and theologi-
cal schools, the difference often appeared
marvellous. What other distinctions has
this city achieved except in medical
science? But, here, all is enthusiasm — all
spirit. Even men who are not public lec-
turers, receive large sums for private in-
struction. To accommodate students rooms
are handsomely furnished with libraries,
apparatus, models, &rc, in various parts of
the city, and thus a promising corps of fu-
ture lecturers are already in the harness.
If we inquire how came the Philadelphians
by these substantial perquisites, the answer
is obvious; that it was because a band of
distinguished medical men, whose names
are familiar to all, took the lead of the
whole country in medical instruction, and
have managed, by means of their excellent
institutions and successors, to keep it. This
is the simple and undoubted reason. Pro-
fessor Chapman said, in his introductory,
that no European physician could gain
solid footing in Philadelphia until he had
abandoned all pretensions to curing his
patients by foreign systems, and had
adopted the prevailing practice of the city. 2

2 Nathaniel Chapman (1780-1853), who was de-
scended from relatives of Sir Walter Raleigh, took
his M.D. at the University of Pennsylvania (1800),
then studied in London and Edinburgh for three
years. It has been written of him that, after Dr.
Physick, "he was the acknowledged head of the
American profession."

Introductory lectures were lectures given before

And medical students that go abroad are
forced to abandon mustaches, foreign
frippery, and foreign systems, on their re-
turn, and adopt the methods and costume
of home.

The dress, equipage and household ar-
rangements of the physicians of Philadel-
phia comport with the elevation of their
character. Indeed, from a slight acquaint-
ance in Boston and New Orleans, and a
very considerable one in New York, I
think the medical men of Philadelphia are
rather obnoxious to the charge of paying
too great attention to these things. Their
fees are very moderate, and complained of
by themselves. I was told repeatedly that
scarcely any man, however distinguished,
charges over one dollar a visit in ordinary
practice. This is the regular charge in such
places as Albany, Troy, Utica and New
Haven. In New York and Boston, men of
similar distinction charge decidedly
higher: one dollar and a half in Boston
and two dollars in New York being the
common charge of fashionable practition-
ers. It should be added that there are men
in both these cities whose services are re-
warded at a much higher rate, and justly;
for the plain reason that men of inferior
talents and responsibilities in other em-
ployments are compensated much more
liberally than themselves. It did not de-
stroy Sir Astley Cooper's acknowledged
liberality in his profession that he accu-
mulated a fortune. 3 And who would think
the worse of the distinguished men of
Philadelphia, who have, by ardent toil and
laborious perseverance, made their services

the actual date of the opening of a school year.
These lectures provided prospective students with
an opportunity to hear some of the professors of
the different schools speak, then choose the school
which they preferred. A further statement about
such lectures appears at about the mid-point of
these letters, below.

3 Sir Astley Cooper (1768-1841) had perhaps the
largest practice of any surgeon. In one year he
earned £21,000. He received one fee of a thousand
guineas from a rich West Indian planter.

PHILADELPHIA MEDK [NE IN 1841

■.><,<(

indispensable to their wealthy neighbors,
should they lay up a few thousands for old
age? Is there any reason in the world why
a physician or surgeon who renders serv-
ices of an extraordinary value should not
be compensated precisely as a lawyer or a
merchant is in the same case? If an Astor
or Girard could add a farm to his posses-
sions by one mental process, should not a
Physick or a Mott receive extra compensa-
tion for an equally supereminent, intellec-
tual exertion? 4 If every body says it is right
for Daniel Webster to be munificently re-
warded for securing, perhaps, an estate to
a family by his great legal knowledge and
power, shall it be pronounced mercenary
if his neighbor, Dr. Warren, should re-
ceive a like generous gratuity for rescuing
from death some beloved member of a
family by his surpassing medical skill? I
truly cannot perceive the difference. Op-
pression and hard-fisted exactions in our
profession I deplore. Among the little or
the great, they are an abomination. And,
whenever a physician finds himself grasp-
ing at a higher annual amount of compen-
sation than men of equal talents receive in
other employments, he may be sure he is
wrong, and will be likely to bring reproach
upon his own profession.

Constituted, however, as our ranks are,
with at least double the number of practi-
tioners needed in our country, the power
of competition must repress extortion and
forbid the hope of wealth among the mem-
bers in general. The late Dr. Miner, of
Middletown, Conn., used to say that four
hundred dollars were an annual average
income for the physicians in that county. 5

4 Philip Syng Physick (1768-1837) has been called
"The Father of American Surgery." He taught at
the University of Pennsylvania from 1805 to 1831.

Valentine Mott (1785-1865) taught surgery at the
College of Physicians and Surgeons of Columbia
University and at Rutgers.

5 Thomas Miner (1777-1841), medical editor,
translator and writer, was said to have been one
of the most learned physicians in New England in
his dav.

The statement appears scarcely credible
when it is remembered that each one must
keep his horse and equipage. To those
only who know something of the "get-
along-ity" of the Yankee character, and the
collateral aids they can secure, will the
statement appear other than fabulous. . . .

Permit me in the next place to call the
attention of your readers to the MEDI-
CAL LECTURES of Philadelphia. To
every physician who visits that city, these
lectures cannot fail to be a matter of com-
manding interest. Every chair was filled dur-
ing my residence there, and the professors in
each of the three schools seemed, to aught
that met the eye of a stranger, to be quite
harmonious. After a most careful scrutiny
and watching for the developments of
character in my brethren who are thrown
into the very rare position of three collat-
eral faculties, almost within stone-throw of
each other, appealing to the same public,
commencing the same probationary ex-
hibition of themselves in their introduc-
tories, on the same week, to hundreds of
candidates who have not yet decided
which faculty to patronize, depending on
the impression they make on the young
gentlemen what success each school is to
share; under the excitement of all these
caustic stimuli, I must say that, in the
mass of these professors, I admired the
magnanimity of their emulation. I said —
"depending on the impression they make."
I do not intimate that the impression from
an introductory is final or omnipotent.
The reputation of the Colleges and of
their respective diplomas, has unquestion-
ably more influence than the introductory
lectures. But how long would the reputa-
tion of either faculty be predominant if its
members should become remiss and repose
on the laurels they have already acquired?

In judging thus favorably of Philadel-
phia competition, I do not profess to go
behind the curtains. I purposely ground my
remarks on what comes up to the eye of a
stranger. Yet I strongly believe that, had

300

HAROLD J. ABRAHAMS AND WYNDHAM D. MILES

there been much dishonorable juggling,
trickery and finesse, in inveigling students
from abroad to this office or that — to this
or the other institution — it would have
been apparent to the eye even of a
stranger, who was admitted with the same
freedom to their offices. I saw no such ap-
pearance. The style of the lectures, too,
was generally of the right stamp. There
was manifest, occasionally, an over atten-
tion to the turn of a period, to the polish-
ing of a sentence, and to the introduction
of sparkling thoughts. In one or two in-
troductories, I thought there was some-
thing slightly theatrical in the manner of
delivery. When we consider that, at each
of the introductories, there are always
enough auditors present, who have de-
cided to belong to the same school with
the speaker, stoutly to applaud by stamp-
ing with their canes, it is greatly to the
credit of the lectures that they so uni-
formly prefer the solid, useful and instruc-
tive, to the brilliant and farfetched.

The introductory of Professor McLean,
of the Jefferson College, was a thing
wholly unique, and defied all classifica-
tion. 6 He appeared at his appointed hour
in the amphitheatre, pale, emaciated and
tremulous, from several weeks' severe
prostration from malaria, encountered in
his professional engagements on the banks
of the Schuylkill. The lecture was in man-
uscript, as I believe were all the introduc-
tories. It was his first from the chair of a
college. He first pointed to his auditory

The name McLean is, apparently, a misprint
for McClellan, probably caused by the inability
of the editor of the Boston Journal to decipher
North's handwriting (typewriters had not yet been
invented). Samuel McClellan (1800-54) was Profes-
sor of Anatomy (1830-32) at Jefferson, and then,
until 1836, held the chairs of Institutes, Jurispru-
dence, and Midwifery, and later the chair of Ob-
stetrics and Diseases of Females, until 1839. There-
after he engaged in private practice. Dr. North
must therefore have attended his lecture a few years
before the date of these letters. (See Gayley, J. F.:
History of Jefferson Medical College, Philadelphia,
1858).

the faculty of the old college, many years
ago, during his medical pupilage. The
person, costume, manner and mode of
lecturing of each professor was described
so minutely that the various portraits were
left with great distinctness on the memory.
The large and attentive audiences of
former days were depicted, and the deep
silence and veneration of the pupils
brought before us in glowing colors. In re-
verting to himself and to his own class, he
compared the acquisition of medical skill
to the pursuit of the diamond. A thou-
sand blows and many prolonged toils are
required to break up the quarry; but when
the gem was won and fairly placed on the
brow, its distinguishing lustre could not
be conclealed nor obscured. So the deep-
laid foundations of medical skill would be
visible in a man's daily performances. As
his chair was that of Midwifery, he illus-
trated the want of this diamond — genuine
preparedness for the various emergencies
of the practice — by introducing the young
physician to his first important obstetrical
case. He described minutely the young
lady, her family, education, marriage, and
her elegant mansion and apartments when
settled in life and awaiting her confine-
ment. He took his auditors into her pri-
vate apartment and showed them what no
man, not even her husband, had really
seen, her drawer, her preparations, her
dresses, Sec, prepared for the little
stranger. At length the nurse and doctor
arrive, and the patient is examined. "All
well." After some hours the face of the pa-
tient becomes flushed, the complaints are
more urgent, the hand is frequently
pressed on the head, and the usual ex-
pression, "I shall die," is heard. All these
things appear common to the medical
man. "But," said the lecturer, "did you
hear her say 'my head aches'?" "No, you
did not hear her say 'my head aches.' "
From not observing this small circum-
stance, puerperal convulsions follow and
death closes the first important case of the

PHILADELPHIA MEDICINE IN 18-11

501

young candidate for popular honors and
employment, not wearing on his person
the aforesaid diamond of professional
skill. The description of this scene was so
graphic that, though most of it was per-
fectly common, 1 cannot resist inserting
this very lame representation, although at
so great a distance of time. I do not know
that Dr. M. will ever again attempt this
graphic method. It certainly would not
bear it frequently. Yet I do not believe
that any of the introductories were heard
with more deep abstraction than this. To-
wards the conclusion, he told the young
men he would give them a secret. "Make
yourselves useful, make yourselves neces-
sary by the undisputed benefit of your
services, and you may dismiss your fears
about employment in any business." From
the irruption of quotations from ancient
and modern languages, it was evident that
in the midst of a pressing business in the
city, he contrived to preserve an intimacy
with his silent companions on the shelves
of his study.

There was one more lecture among the
introductories, of a very different charac-
ter, but equally sui generis, and more
surprising. It was the very lecture, a part
of which you have already re-printed in
your Journal. Dr. Gibson's Introductory
evinced a head that could plan and exe-
cute, and a heart that had the courage to
ordain, laws for himself. 7 The common
conventionality of authors and lecturers
were as cyphers in his estimation. He pro-
posed for his subject his own autobiog-
raphy, not only without acknowledging
anything improper or unusual, but with
the declaration that if a man did not
publish his own merits nobody else would
do it for him. He began with his early life,

'William Gibson (1788-1868) studied at the Uni-
versity of Pennsylvania, Princeton, and the Uni-
versity of Edinburgh (M.D., 1809), was one of the
founders of the University of Maryland Medical
School, and was professor of surgery at the Uni-
versity of Pennsylvania (1819—55).

and conducted us to the day and hour of
the lecture. It was an interesting biog-
raphy, particularly t<> a medical class:
and had it been told by another, it would
have been heard with unminglcd pleasure
and admiration. During its progress, I
made many efforts to divest myself of all
former notions of propriety, and to make
myself believe that the man who had
achieved such things in the surgical and
medical world, and who evinced such un-
deniable proofs of genius, had not mis-
judged in striking out a new course for
himself in interesting and instructing his
class; and, although I have recurred many
times in my recollections to the mingled
emotions of amazement and applause
which I experienced while hearing that
lecture, I am still undecided whether Pro-
fessor Gibson, in addressing six or eight
hundred young men, many from the South
and West (himself being a Baltimorean),
did not gain as much by his unparalleled
boldness and adroitness as he lost by his
egregious aberration from the rules of
modesty. I am sure Professor Gibson
would not be offended should this sheet
ever meet his eyes, because there was no
concealment about his lecture. Its scope
was explicit, avowed, without apology;
nay, has been submitted to the public, I
know not with what modifications by
means of the press. He closed his lecture
by a labored and most ingenious represen-
tation of the advantages of the venerable
Institution in which he occupied the chair
of surgery.

I purposely limit my specification of the
lectures at the Colleges to these two. It
would be very agreeable to enlarge on the
varied excellences of these annual intro-
ductories; but it would be taking liberties
with your pages entirely inadmissible.

I shall trouble your readers with one
more topic, and that is CLINICAL LEC-
TURES. In this particular, Philadelphia
certainly stands pre-eminent. I know from
personal inspections, often repeated, that

302

HAROLD J. ABRAHAMS AND WVNDHAM D. MILES

the New York Hospital has many advant-
ages for clinical lectures. The Boston Hos-
pital, too, from its excellent arrangements
many years ago, I must suppose to have
kept on in the march of improvement. But
the Blockley Almshouse, on the west side
of (he Schuylkill, contains a pauper popu-
lation of from two to four thousand; and
among these, I was repeatedly told that
four hundred patients is a low number,
exclusive of the maniacs. Imagine all these
to be lodged in one range of buildings, on
moveable beds; and on the same floor with
these wards, and in a central position, a
very large amphitheatre constructed with
every contiguous convenience for opera-
tions and exhibitions, into the centre of
which the patients can be brought with
perfect ease on their beds. Suppose, more-
over, that the whole of these patients are
divided between the University and Jeffer-
son College, each of which Institutions
has its own resident and consulting physi-
cians and surgeons; and that these men,
half on Wednesday and half on Saturday,
select from their respective wards such
groups of diseases as are most interesting,
and exhibit them to their classes with the
accompanying prescriptions and opera-
tions. Can such an arrangement fail to be
useful? I have occasionally mingled in the
groups of a clinical lecture, standing
among the beds of the patients in a hos-
pital. This is well when the circle of pupils
is small. But at the Blockley, by means of
the amphitheatre and the blackboard, two
hundred can share very well the advant-
ages of a clinical lecture. While sitting in
their seats, after the patients are carried
out, the specimens of morbid anatomy, the
result of recent dissections, are passed
round to the students, who can examine
them thoroughly without the hindrance
of the dissection, and contrast them with
what they previously saw and heard of the
disease. At each session about three hours
are spent; one half devoted to the surgical
and one half to the medical clinique. The

respective institutions are not confined to
their own public lecturers in selecting a
man for the clinical chair. At the time of
my visit Dr. Gerhard was giving the medi-
cal clinique in the chair of the University
or old school, at the Blockley Hospital,
which post entitles him to the superin-
tendence, as a consulting physician, of one
half of all the medical cases in the institu-
tion. 8 This appointment was no leap in the
dark. I cannot resist saying that I have
never seen a physician who, I should
fancy, would more resemble Dupuytren,
in his habit of investigation, than this
same Dr. Gerhard. 9 I should imagine he
had long taken up his abode in the hos-
pitals of Europe. Like many of the medical
aspirants of Philadelphia, he has served
his time among foreign hospitals, and, I
believe, by the side of Dupuytren. Slender
and erect in his person, with a keen eye,
and a face undoubtedly made thin by the
midnight lamp, he assembles his group of
patients in the middle of the theatre,
with his auditors on seats rising around
him, gives a clear and succinct description
of the disease, enters most fully into its
pathology, and with a familiarity and
comprehensiveness that would surprise
many a veteran practitioner who listened
for the first time to a clinical lecture,
comes up boldly to the diagnosis, specify-
ing the seat and extent of the lesion, and
clearly distinguishing it from its counter-
feits; evinces no reserve nor dodging
while on the prognosis, and discusses the
methodus curandi on a basis evidently
eclectic and rational, and drawn from
prolonged and accurate observations of

8 William W. Gerhard (1809-1872) was educated
at Dickinson and University of Pennsylvania (M.D.,
1830). He studied medicine under famous French
physicians in Paris and from 1834 was resident
physician and later visiting physician of Philadel-
phia hospitals. At the time of North's visit he was
assistant professor of institutes of medicine at the
University of Pennsylvania.

"Guillaume Dupuytren (1777-1835) was a famous
French surgeon, well-known to American medical
students studying or visiting in France.

Philadelphia medicine in ihh

the multifarious plans in Europe and
America. Bating a slight bearing which I
thought was apparent towards the expect-
ant method of the French, the therapeu-
tics of Dr. G. appeared to be such as our
best practitioners in Boston, New York
and Philadelphia would approve. So com-
pressed and rapid are his statements and
reasonings, that you have no chance for
idling, but are dragged on, on to the end;
and you then feel that there is much that
the young gentlemen must inevitably lose
from their want of previous clinical ex-
perience and practical acquaintance with
the subjects discussed.

From attending a single clinical lecture
of Dr. Pancoast, from the Jefferson Col-
lege, I think he may be set down as the
opposite of Dr. Gerhard. 10 Dr. P. is pro-
longed, exact, particular; and seems re-
solved that his pupils shall never forget
the facts of the disease in question, and
the steps of his operations. These lecturers
are both good, but yet very different in
method.

Of Dr. Gibson, the collaborator of Dr.
Gerhard, I have already spoken. Surgery is
his passion, I am told, and he is quite at
home and unembarrassed before the class.
I incidentally learned that some of his
pupils were offended and indignant at
some of his moral allusions and intima-
tions respecting their own tastes and
habits while lecturing on the venereal dis-
ease. As I entered the room after the lec-
ture commenced, 1 did not hear the offen-
sive expression; and from Dr. Gibson's
high and commanding qualities, both as
an operator and lecturer, I will not believe
that he would mar those shining talents
by the exhibition of the underworkings of
an impure heart. In a medical man it is
bad enough, in all conscience, to be sure
that you discover in him the turbid work-

10 Joseph Pancoast (1805-1882), educated at the
University of Pennsylvania (M.D., 1828), was physi-
cian to the Philadelphia Hospital, professor of
surgery at Jefferson, from 1838 to 1847, and professor
of anatomy from 1847 to 1874.

ings of internal defilement But when a
man of solid talents and high acquire-
ments is understood to discover a relish for
obscenity, and a desire to inflame rather
than repress the headstrong promptings
of young men, removed from the re-
straints of mothers, sisters and acquaint-
ances, and thrown loose upon the purlieus
of a wide city, it becomes us to pronounce
the whole a mistake. How improbable that
Dr. Gibson, in Physick's own chair, ob-
tained by dint of his own merit, and re-
tained by general consent, and feeling a
strong desire for the honorable career of
his pupils, should so far mistake his policy
and his duty in lecturing to the north and
south, east and west, as to allow one breath
of suspicion to fall upon the purity of his
taste or the integrity of his intentions.

As I have named three of these lectures
in the Blockley Hospital, permit me to in-
troduce for one moment the only remain-
ing one, Dr. Dunglison, of the Jefferson
Medical College. 11 There can be no mis-
take in saying of Dr. Dunglison's medical
pursuits, he is "totus in Mis." In addition
to his private pupils and private practice,
he promptly fulfils his hour four times a
week in the College, and has the supervi-
sion of half the Blockley Hospital, besides
his weekly lecture there. These, with the
common et ceteras of a city life, would keep
a man tolerably busy. But, in addition to
this, he writes more books, as your readers
well know, than any monk with the world
shut out could originate; books, too, that
the medical world demand to be reprinted
again and again. "Labor, ipse voluntas."
It is evident, Mr. Editor, that while the
rest of us are asleep, this man is wide

"Robley Dunglison (1798-1869), born in England,
studied medicine in Edinburgh, Paris, London and
Erlangen, came to the United States at the invita-
tion of Thomas Jefferson to teach medicine at the
University of Virginia, later taught at the University
of Maryland and, when North visited Philadelphia,
was professor of the institutes of medicine at Jeffer-
son. Dunglison's name was familiar to generations
of medical students through the many popular
books he wrote.

304

HAROLD J. ABRAHAMS AND WYNDHAM D. MILES

awake at his nocturnal labors; and yet he
has the personal appearance of a well-
fed, easy, plump, care-shunning body. Pro-
fessor Dunglison's lectures are delivered
with rapidity and clearness of enunciation,
and I need hardly say they are rich and
instructive.

It should be said, that, in addition to
the Philadelphia Hospital, over the
Schuylkill, just described, the original
Pennsylvania Hospital yet remains in its
excellence in the very heart of the city. So
silent and clean and airy are its apart-
ments, so urbane the officers and medical
attendants, that I often felt constrained to
loiter and seek retirement in the deep
seclusion of its walls. Indeed, had I been
taken sick in the city, I am almost certain
I should have applied for one of its private
apartments. It is scarcely possible for a
public house to afford you equal comforts.
The establishment occupies a whole
square, and it is as still as a lodge in the
wilderness. A change of medical officers
occurred during my visits, and in addition
to the requisite medical skill, these gentle-
men, one and all, resident and consulting,
manifested to me the most uniform kind-
ness and urbanity. Capt. Marryatt and
other Europeans have denominated the
Blockley establishment the "beggar's pal-
ace," and none who have seen it can deny
the propriety of the cognomen. 12 But this
old Hospital, with Penn's statue in bronze
in the front yard, its tall ceilings, wide
halls, ample library and apparatus, and
all things so quiet and dignified, and even
sylvan, is fit to be called the nobleman's
nursery. Although the wards are not now
very full, the mass having been consigned
to Blockley, yet even now there is an in-
teresting field for pathological research
and observation. The same mode of visits

12 Frederick Marryat (1792-1842), a captain in the
British navy and a novelist, visited the United States
in 1837-38 and published his impressions in A
Diary in America, with Remarks on its Institutions
(1839).

and lectures exists here as at Blockley, this
institution being the prototype; excepting
that the clinical lectures are delivered here
by the bed-side.

Besides these two great institutions al-
ready described, there are I know not how
many private institutions, dispensaries and
specialites. I visited several, and found
them cooperating in the great business of
medicine. In short, the business of teach-
ing and lecturing seems to be the favorite
employment of the profession. There may
be twice as many out of the three Colleges
giving lectures and instruction as within
them. Some may do this simply for its
emoluments, or from attachment to the
business. Yet there are three rows of pro-
fessional chairs in plain sight, any one of
which would be a post of honor to the
younger members of the profession. In this
way the Colleges, although they are not
limited to Philadelphia, have a corps of
candidates under their daily observation.

We see, then, that the foundations of
medical science are deeply laid in this
city, that its fame and emoluments are
eagerly sought by men of commanding
powers, and that their rewards are of no
stinted character. For many years medicine
must, in the nature of things, stand prom-
inent in the City of Brotherly Love. She
has disciples who toil over the midnight
lamp through the love of their calling and
a desire to see it exalted: from many such
I have received, and beg to acknowledge,
the cordial welcome and the liberal inter-
change of professional opinion; and I ask
permission, in conclusion, to say that,
could many of my readers, who have been
absent from schools and lectures many
years, spend two or three weeks — nay, a
winter — in a medical pilgrimage to Phila-
delphia or other of our flourishing schools
where clinical lectures could be attended,
they would in my opinion find the sacrifice
greatly to enhance their future respecta-
bility and usefulness.

Memoir of S. k

1892-

By FREDERICK C.

SJERVIS BRINTON was born on
September 2, 1892 and died on
• September 19, 1969. He had four
uncles who served in the Civil War as
surgeons, one of them as Surgeon General
in the Army of the Potomac. His father
was an M.D. and encouraged his son to
become a doctor. Jervis attended George
School and then Swarthmore College for
three years. He was graduated from the
School of Medicine of the University of
Pennsylvania in 1920, his course having
been interrupted for a short term of serv-
ice in the United States Artillery.

In 1922 he married Edith Virden
Ketcham of Chestnut Hill and there were
two children, Jervis, Jr., and Ann Raab
Brinton, and seven grandchildren.

He began general practice in Ardmore,
Pennsylvania, after two years as an intern
in medicine and obstetrics. He then be-
came Instructor in Medicine in the Uni-
versity of Pennsylvania Graduate School
and Attending Physician to the Bryn
Mawr Hospital, where he later became
consultant Physician. At various times he

• Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

fervis Brinton
1969*

SHARPLESS, m.d.

was President of the Main Line Medical
Society, Chairman of Medical Defense for
Lower Merion Township, and a member
of the Medical School Board, during which
service he was instrumental in founding
legislation for the compulsory vaccination
of students against diphtheria. For these
two latter services, he received medals. He
was a member of The College of Physi-
cians of Philadelphia, the American Medi-
cal Association and the Merion Golf Club.

Dr. Brinton's first wife died in 1954. In
1956 he married Phillippa Queen of New
York and Washington, D. C. In 1960 he
underwent surgery by Dr. Michael E. De-
Bakey, who replaced a large section of the
aorta with a woven dacron tube. The op-
eration was followed by serum hepatitis, a
result of many blood transfusions, which
endured for four years. After retirement,
Dr. Brinton lived in Avalon, New Jersey,
and Palm Beach, Florida, and attained
prominence as a skillful golf putter.

No account of him would be complete
without mention of his pleasing personal-
ity, his continuous good humor, and his
capacity for friendship which endeared
him to all who knew him.

305

Memoir of John Westgate Hope
1914-1969*

By C. EVERETT KOOP, m.d.

JOHN WESTGATE HOPE died at the
Hospital of the University of Pennsyl-
vania on June 13, 1969, a victim of a
disease around which much of his profes-
sional life was centered. Few men have ever
been as gifted as Dr. Hope in the manage-
ment of grieving parents whose children
faced inevitable death from cancer.

Dr. Hope was born in Chicago, Illinois,
on May 6, 1914, to Reginald and Dorcas
Hope, who subsequently moved from
( ;iii< ago to Coronado, California.

Following graduation from Stanford
University in 1936, Dr. Hope entered the
Medical College of the same university
and, after graduating therefrom, served
residencies in pediatrics and in radiology-
pathology at the Stanford Medical Center
from 1940 to 1942. He then served in the
United States Navy from 1942 to 1947,
leaving the service with the rank of Lieu-
tenant Commander. He came to Phila-
delphia in 1947 to take further radiologic
training under Eugene P. Pendergrass at
the University of Pennsylvania School of
Medicine and in 1951 became Radiologist-
in-Chief to The Children's Hospital of
Philadelphia. He had joined the faculty
at the University in 1951 as Assistant Pro-
fessor; from 1966 until his death he was
Professor of Radiology in the University's
School of Medicine.

John Hope was thrust into the midst of
a developing specialty in pediatrics and
accepted the challenge as a pioneer en-
gaged in finding new techniques in the
examination and treatment of children by

* Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

radiologic means which have now become
time-honored throughout the country. He
had a remarkable ability for anecdotal
teaching and as he unfolded the clinical
history centering about the fdms he was
about to demonstrate, the listener could
capture a remarkable picture of a clinical
entity radiographically proven and not
soon to be forgotten.

Although his teaching abilities took him
many places in this country and abroad,
John Hope became one of the stalwarts of
the staff of The Children's Hospital where
he was not only the father figure to many
of the younger staff men but also an avail-
able counselor to the families of the chron-
ically ill children for whom his sympathy
was always real and never assumed.

Dr. Hope was a diplomate of the Ameri-
can Board of Radiology and a member of
the Radiological Society of North Amer-
ica and of the American Roentgen Ray
Society; a fellow of the American College
of Radiology; a past president of the
Society for Pediatric Radiology; and
secretary of the Inter-Society Committee
for the Registry of Radiologic Pathology
of the Armed Forces Institute of Pathol-
ogy. He served as consultant to the latter
organization, as well as to Philadelphia
General Hospital, Jeanes Hospital, U. S.
Naval Hospital and the U. S. Veterans
Administration Hospital, and Mercy-
Douglass Hospital. He was a member of
Phi Beta Kappa, Alpha Omega Alpha,
Sigma Xi, the John Morgan Society, the
Blockley Radiological Society, and hon-
orary or affiliating member of a number of
professional societies abroad.

He is survived by his wife, the former

306

MEMOIR OF JOHN'

Mary Crane, and by a son, William Aborn
1 lope.

Endearing himself to countless residents
who rotated through The Children's Hos-
pital for his unique teaching, he was held

WESTGATE HOPE 307

in high esteem. One group of retiring
residents presented him with a plaque
which expressed in pun form what many
of us came to believe: "To Dr. John Hope,
the greatest hope for little people."

Memoir of David Warren Kramer
i 890-1969*

By HAROLD L.

DAVID WARREN KRAMER, born
November 15, 1890, in Philadel-
phia was graduated from Jefferson
Medical College in 1912. He interned at
Philadelphia General Hospital. His sub-
sequent medical career was largely devoted
to these two institutions.

After service in World War I in the
Medical Corps of the British and United
States Armies, Dr. Kramer was appointed
Assistant Visiting Physician on the medi-
cal service of his mentor, Dr. Solomon
Solis-Cohen, at Philadelphia General Hos-
pital. He became a chief in 1939 and an
honorary consultant in 1956. Dr. Kramer
served as President of the Medical Staff
in 1952 and 1953.

His two absorbing interests were diabe-

• Prepared and published at the request of the
Council of The College of Physicians of Philadel-
phia.

ISRAEL, m.d.

tes and peripheral vascular disease. He
organized the diabetes clinic at the Jewish
Hospital and the vascular clinics at Phila-
delphia General and Jefferson Hospital.

Dr. Kramer was on the faculty of Jeffer-
son Medical College and became Associate
Professor of Medicine in 1948. In 1962 he
was honored by the Delaware Valley Dia-
betes Association, receiving the J. Howard
Reber Memorial Medal. Author of more
than 50 papers on diabetes and vascular
disease, he served on the editorial board of
Angiology.

His personal life was repeatedly marred
by tragedy: his first wife died in childbirth,
his only child died of breast cancer, and
his second wife died after prolonged ill-
ness.

Dr. Kramer continued his practice at
2007 Pine Street until shortly before his
death in Jefferson Hospital on May 13,

1969.

308

Memoir of Eu£
1903-

By ORAM R.

EUGENE A. MEYER, M.D., was
born on August 30, 1903 in Phila-
delphia, Pennsylvania. His father,
Eugene E. Meyer, a native of Frankford,
Germany, came to the United States in his
late teens. Dr. Meyer's family later moved
to New Jersey and he attended the Pal-
myra High School, where in addition to
being a satisfactory student he was a popu-
lar football quarterback.

He received a B.S. degree from Hahne-
mann College of Science in 1923 and an
M.D. degree from Hahnemann Medical
College in 1927. After graduation he
married Ida Hafner, served an internship
for one year at West Jersey Hospital and
then started general practice in Moores-
town, New Jersey. Soon after starting
practice, he began work in otolaryngology
which he assiduously pursued and which
enabled him to become certified by the
American Board of Otolaryngology in
1936. In June 1942 he entered the U